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#42 Learner Autonomy With Ben Kinnear, MD MEd

June 5, 2024 | By

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Transcript available via YouTube

Join us as we discuss all things learner autonomy with returning guest Dr Ben Kinnear.  We cover the value of supporting learner autonomy, practical tips for doing this in practice, challenges related to bias in health care and education, and when to let your learners fail to help them grow.

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Meet our Guest:

Dr Kinnear is a Med-Peds hospitalist in Cincinnati, Ohio and is associate program director for the Med-Peds and IM residency programs. His interests include competency-based medical education, novel assessment strategies, evidence-based learning, and coaching. He is currently a PhD candidate at Maastricht University’s School of Health Professions Education where he is studying validity argumentation and argumentation theory. Ben spends most of his free time with his wife and two daughters hiking, playing board games, and telling AMAZING dad jokes.

Show Segments

  • Intro, disclaimer, guest bio
  • Updates and Introductions
  • Picks of the Week
  • Case From Kashlak
  • Understanding Autonomy and Supervision
  • Self-Determination Theory and Autonomy
  • Reflecting on Personal Experiences
  • Balancing Autonomy with Different Levels of Learners
  • Autonomy and Risk in Medical Education
  • Benefits of Learner Autonomy
  • Challenges in Promoting Autonomy
  • Promoting Autonomy in the Clinical Setting
  • Addressing Disparities in Autonomy
  • Allowing Failure and Reflecting on Autonomy
  • Framing Autonomy as an Educator Milestone
  • Promoting Autonomy in Supervisors
  • Take-home points

Learner Autonomy Pearls

  1. Supervision and autonomy are closely related, but they are independently titratable variables for how we manage our teams and train learners. 
  2. Fostering autonomy can help improve intrinsic motivation, encourage self-directed learning, and help develop trainees who are ready for independent practice.
  3. You can never communicate too much about autonomy.  Be open with learners in terms of what they’re looking for and what you’re seeing with their behaviors.  
  4. Use the four S’s framework (Silent, Second, psychological Safety, Secret moves) to promote autonomy with learners.
  5. If and when you let learners fail, be transparent about the fact that they were allowed to fail for the sake of autonomy and help them work through it and unpack it.

Learner Autonomy Notes

Definitions

Autonomy is an internal sense of empowerment someone has- the feeling that they have agency, volition, or ability to act in the world.  Educators can foster or squash this.  Supervision is external oversight- someone else is monitoring them and can step in if needed.  Supervision and autonomy are closely related, but they are independently titratable variables in terms of managing our teams and training learners.  Sometimes supervision is not something we can change very much (because of ACGME rules for example), but autonomy is something Dr. Kinnear thinks as educators we have a lot of control over in the clinical learning environment.

Trust implies a sense of vulnerability or risk.  Entrustment is the act of giving trust to someone else. It means being vulnerable in the moment to their actions.  In medical education, we are vulnerable to a learner’s actions in patient care; entrustment comes with the act of being vulnerable to our learners by decreasing the supervision that they are getting with a given patient.

Self determination theory is focused on human motivation. Humans sit on a spectrum from being intrinsically motivated to extrinsically motivated.  Ideally as educators, we want people to be intrinsically motivated.  To foster intrinsic motivation, self determination theory says that humans have three psychological needs:  a sense of competence, a sense of relatedness, and a sense of autonomy.  Therefore, if we want to foster intrinsic motivation for things like self-regulated, self-directed learning, then we have to foster a sense of autonomy. We have to help them feel like they have agency both in the clinical care that they’re delivering, but also in their own learning (Baldwin 2012).

Autonomy across Health Professions Education

Dr Kinnear’s training and teaching is primarily in the Med-Peds space, and he appreciates that autonomy may be conceptualized or enacted differently in different fields.  He recommends approaching this with a sense of humility and curiosity when we’re working in interprofessional teams. 

Medical Students and Autonomy

Dr Kinnear points out that with autonomy comes risk.  If a space is not psychologically safe, learners may prefer less autonomy as it reduces the risk of failure.  Medical students, especially at institutions that have tiered grading systems, may feel the need to perform well because so much of their future depends on the grade that they receive.  If they try to have a lot of autonomy and make a mistake, then that creates a risk for a lower grade, rather than taking minimal amounts of autonomy and just doing the job well (Bullock 2022).  Residents have less risk because they do not tend to be graded.

Benefits for promoting learner autonomy

Autonomy promotes self directed learning and development, as per self determination theory.

Encouraging independent thinking and decision making, while still under some supervision, allows learners to build confidence while still in a supported environment.  This can allow for more comfortable transitions to independent practice and reduce imposter syndrome.

Autonomy can promote self-directed learning.  The work of Anders Ericsson on deliberate practice highlights that we need to continue being deliberate with our learning after training to develop expertise.  If we want to be true experts, we have to continue with that effortful, deliberate practice and learning, even after we are not required to by training (Ericsson 2008).

Patient safety is often cited as a concern for why to limit learner autonomy, but Dr Kinnear highlights that many of our learners do not simply represent risk to patients, but have experiences or skills that enrich patient care.

Dr Kinnear highlights that increasing autonomy allows an educator to really see the learner’s skills and knowledge, allowing them to provide more targeted feedback because the learner had to work through a problem independently first.

Challenges to Promoting Autonomy

Patient safety is often highlighted as a concern here.

Time can be a constraint- it can take longer to work through nuanced or challenging decisions.

Managing our own emotions can be a challenge to autonomy.  More risk aversion or less flexibility can make it more difficult for an attending to allow autonomy.   

This is a significant cognitive load for an educator to manage the team and balance autonomy while caring for patients, observing skills, and balancing multiple levels of learners. 

While you can promote autonomy without reducing supervision, there does come a point where the only way to give more autonomy is to allow unsupervised practice, especially for our more advanced learners.  Sometimes reduction of supervision is constrained by our training system.

Tips for Promoting Autonomy

4-S’s is a helpful framework for actions to promote autonomy.

Silence: This is not my space to talk.  Redirect patient and family to the learner.  Allow time and space for the learner to come to their own decisions, even if it is a dicey situation.

Second: Allow the learner to be the leader, the educator is second.  Enter the room after the learner, allow them to speak first, position the learner in the room as more immediate to the patient, allow time for the learner to share opinions first.

Safety: Psychological safety- avoid saying no as the educator.  Instead of shutting down an answer, reframe to say, yes, and what might be another option to cover xyz or offer up an alternative saying, yes, and this treatment offers the benefits of your recommendation plus would also cover abc.

Secret moves: How can you facilitate the team discussion efficiently without letting residents know that you’re doing it?  Can you quietly nudge the team along, making sure that you’re encouraging your learners to teach one another, without you taking those roles or explicitly letting them know that you’re kind of pulling the levers. (Crocket 2019, Torbeck 2015)

NOTE, Dr Kinnear found this 4S framework at a Quality Rounds Initiative from Wisconsin, if you have a citation for us, please share! 

Dr Kinnear recommends being direct around discussing autonomy.  If you see a learner deflate on rounds after their clinical recommendations were shut down, take some time later on to have a private conversation to name that emotion and see how the learner is feeling about it.  

Reflecting on experiences you had as a learner that felt frustrating because your autonomy was taken away can help keep you in the experience of what a learner may be feeling.

While knowing a learner’s stage of training may be helpful to start to titrate autonomy, different learners will be at different places depending on their skills and experience.  Dr Kinnear recommends asking some simple questions to get a sense of how much autonomy the learner wants.  For example, Is this your first time in this clinical environment? What types of things are you feeling confident about?  Or, what areas are you not as confident and you want to not have as much autonomy in your decision making?  Some learners may lack insight into where they need more or less autonomy- indirect cues like things falling through the cracks, patient encounters not going very well, or team not functioning efficiently, are sometimes clues that despite the fact that somebody wants autonomy, that they may not be ready for it at that moment.

Tips for Micromanagers/Res-Attending

Dr Kinnear recommends you reflect back to yourself as the educator why you are having trouble letting go of control?  

Ask your learner for feedbackHey, how did I do today on rounds? Was I stepping on your toes too much? Did you have space to make decisions?  I felt like maybe I jumped in a little too early here, what do you think?

If available, take advantage of peer observation and feedback programs. (Mookerjee 2022)

Disparities in Autonomy

Members of historically marginalized groups may be given less autonomy in training (Lund 2024).  Dr Kinnear suggests considering two approaches that may improve this.  Reflexivity, a practice from qualitative research, is an explicit reflection on how your identity and background may impact your response to a learner.  Looking at data can be helpful too.  For example, do you see differences between people of different identities and backgrounds on entrustment supervision ratings?  Experiential data, asking learners about their experiences with autonomy or experiences being treated differently based on their identity, can help identify areas of bias.

Allowing Failure

To fully allow autonomy, as an educator, you need to let your trainees fail sometimes. “Fail” does not mean failing a test, but rather to learn experientially in a way that allows for things to be imperfect while still protecting patients and learners.  Dr Kinnear builds on Dr Klasen’s work to think about promoting autonomy by talking about allowing failure with our learners.  Not just to debrief about the failure, but to say, I saw that failure happening and I let it happen, and here’s why I let it happen.  Being transparent and explicit with that can create psychological safety by generating  a culture of acceptance that failure is going to happen.  Dr Klasen highlights these failures should have a low risk to the patient and have the opportunity to be a formative experience because of learner and educator factors (Klasen 2019, Klasen 2022, Klasen 2023).

Take home points:

You can never communicate too much about autonomy. Be open with learners in terms of what they’re looking for and what you’re seeing with their behavior.  Be explicit about the difference between autonomy and supervision.

Use the four S’s framework to promote autonomy with learners.

If and when you let learners fail, be transparent about the fact that they were allowed to fail for the sake of autonomy and help them work through that and unpack all that.


Links

  1. Demon Copperhead, novel by Barbara Kingsolver
  2. School of Chocolate Netflix show
  3. Our prior podcast with Dr Kinnear on Competency Based Time Variable Medical Education and his Timeless Pilot
  4. Ralph the Rooster, by Maja Kinnear

Goal

Listeners will gain a deeper appreciation of how learner autonomy can be amplified and how it impacts both faculty teaching and trainee development.

Learning objectives

After listening to this episode listeners will be able to…

  1. List the benefits of and difficulties with supporting and promoting learner autonomy in health professions training.
  2. Distinguish between learner autonomy, trust, and lack of supervision.
  3. Recognize strategies to promote learner autonomy in day-to-day faculty health professions education.

Disclosures

Dr Kinnear reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Heublein M, Kryzhanovskaya E, Kinnear B, A Niranjan-Azadi. “#42 Learner Autonomy. The Curbsiders Teach Podcast. https://thecurbsiders.com/teach.  June 5, 2024.

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Episode Credits

Producers/Hosts: Molly Heublein MD/ Era Kryzhanovskaya MD
Writer/Infographic: Molly Heublein MD
Reviewer: Ashwini Niranjan-Azadi MD
Guest: Ben Kinnear MD MEd
Technical support: Podpaste
Theme Music: MorsyMusic

CME Partner

vcuhealth

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

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