Andy thanks for coming in. This is Andy Oden, who is a hospitalist at the University of Michigan. And then also at the Veterans Administration in Ann Arbor, tell me a little bit about your practice. >> Absolutely. So As a hospitalist, I, provide care for, a broad range of inpatients, both in, teaching, environments with, medical students, and internal medicine residents. And then also, independently without, without learners. >> Okay. So, Andy and Meg and I have been doing this workshop for a while now kind of trying to teach faculty about how to, how to entrust and how to give responsibility and autonomy to their residents. And I've actually, I've learned quite a bit from Andy in this process. So, Andy, how do you know when a resident's ready. Like, how do you determine how much to trust them? >> It's a very, very important question Sally, and it varies a lot depending on the, the level of training of the resident, and so brand new interns in July, when they've just started are going to require quite a bit more oversight. >> Mm-hm. >> Than 30 residents who are getting close to finishing their residency. >> Mm-hm. >> But even more than just a linear relationship with their years in training, I think there are a lot of personal factors that can have a big impact. So certainly a resident's medical knowledge, their. Their confidence, their attention to detail. All of these factors are going to play a huge role in how much autonomy I end up granting to them. And I think it's, it's one of the most fundamental questions that we as medical educators have. Because we are training medical students and residents to become independent physicians. And to do that, they need to be making decisions, they need to be making judgements, on their own, and so doing this well, I think, is one of the most important roles that I have in my job. >> Mm-hm. I think that's true, because in the end we want them to practice independently, but they can't do it unless they're doing it along the way. >> Absolutely. >> Yeah, and so, so when you're working you know, when you're the attending, supervising, how do you, how do you entrust? What kind of things do you do? >> Yeah, so there's a, there's a few different things that I'll do. I, I think one of one of my favorite things to do is is to actually be a stealth rounder. >> Mm-hm. >> And so I have the advantage of being able to collect data from the computerized medial record, looking at things like vital signs and labs, consultant notes medical lists. And I can do that behind the scenes. And I often won't tip my hand. When we're rounding. And being able to, to hear which of the residents and which of the interns, I have picked up on those crucial pieces of information. Really tells me a lot about, who I can entrust larger decisions to and who I can give more responsibility to. So the, the, the background rounding is a big piece of what I end up doing. And then also I think a lot of a lot of what I do is is making sure that my interns and residents understand the decisions that they're making. Because with the compression of medical education and the, and the duty hour restrictions that we have for our residents there're fewer and fewer cases that residents are being exposed to. And one concern is that they may have only seen a case or two of diabetic ketoacidosis. >> Mm-hm. >> And they may be managing this in the way that they had managed it before but there are some subtle nuances. >> Mm-hm. >> And so I will probe the interns and probe the residents to make sure that they have the depth of understanding about the variations in practice and the variations in patient presentation. >> Mm-hm. >> And the more that they're able to tell me and show me that they understand, the more apt I am to give them those decisions. >> Mm-hm. >> And so, for, for particularly high functioning second or third year residents, you know, I may, for new admissions give them the give them free reign to say, you know, if you need to. Order this particular test or call this particular consultant, do so. Always call me if you have concerns, or, you know, we can round on any patient at any time. But, for those that I, I have more faith in and those that I trust more, I'll give them more of those, those opportunities. >> And you kind of do it explicitly to say hey, you know you, you don't need to call me. Those sorts of things. >> Yeah it, it, it's a, it's a mix. there, there's certainly some residents and, and particularly the ones that are maybe a little bit more reluctant. >> Mm-hm. >> And yet, more skilled, where I'll tell them you can fly, you can do this on your own. Whereas we have other residents who may be more confident. But perhaps their, their clinical skills are somewhere in the middle. And and, and those I'll, I'll have a bit of a. A shorter leash but then also we'll do even more behind the scenes. And because I know that they'll be stepping out on their own more independently. And I'll be working more of my job is involved with brining them back in and making sure they're considering all the decision that they're making. >> Right, right so that they're safe in the patients that they have, but they're also thinking about the future patients and the other things that might happen. >> Right. >> And so, so how about students, so what do you, how do you manage students and student autonomy, cause they don't, they don't know that much sometimes. Well, you'd, you'd be surprised, and, and students are tricky, because medical students don't have the ability to write, orders, at least independently, and they have much less clinical experience than, than interns and residents do. but, but I've found that, if you can get them asking the right questions. >> Mm-hm. >> They can really surprise you with their ability to make decisions. And so for, for students I trust them to to to gather information. And I'll verify a lot of that. But I also really focus on pushing them to, to, make some of those decisions, and when, when I push them to make decisions it actually tells me a lot about their due diligence, things like taking a medication history, taking social history, doing a physical exam, because they have to incorporate all of that information into the decisions that they make, and so by spending more time on management discussions. It actually gives me a very in depth view of everything else that they're doing leading up to that. >> Mm-hm. >> And and, and so with students in particular because of their limitations and because of the structural limitations, that to me seems to be a very efficient way of of learning a lot of information about them, and about what they're doing. >> Yeah that's, I think that's pretty helpful. But their particular I don't know, residents, or patients, in whom you have a difficult time or an easier time doing, giving autonomy? >> Yeah, so, I'd say, probably the most difficult situation for me to give autonomy is with critically ill patients, and, as a hospitalist, I don't routinely care for patients in an ICU. But I do regularly supervise and attend codes, and we will also frequently have critically ill patients who have had a change in clinical status on the, on the wards, and I find it is tough for me to not jump in and try to run the show. During codes or during some of these other hyper acute situations. And and so the way I found that I've gotten around that is, is to be very mindful. And to, and to look for specific things. So with codes for example, I'm looking at how the resident is coordinating with the other team members. Are they utilizing close-loop communication are they making the right decisions at the right time. And that, I find allows me to, to be able to take a deep breath, take a step back, and let them run the show a little bit more. but, but necessarily when someone is, is, in a cardiac arrest situation, or, or in, critical illness, there needs to be a bit of, a shorter leash, but that doesn't mean that you can't give, the resident the opportunity. >> Yeah, yeah, no right, that's really helpful. And so can you just summarize, kind of, the things that you do? >> Absolutely. So I, I think the the, the first thing that I do is is the background chart review, or the stealth rounding. >> Mm-hm. >> Which tells me a lot about about the residents, what they know, what they're finding out. I probe quite a bit on decision making because it integrates so much of all of the un, other information that that they should be pulling in. That they should be gathering from the patient and from consultants. And then I'm very mindful about what specific situation will allow me to do in terms of entrustment and will allow me to balance the needs of our students and our residents with the needs of the patient. >> Good, that's helpful. Thanks. >> Thank you very much.
