‘It’s a cultural expectation…’ The pressure on medical trainees to work independently in clinical practice
Abstract
Context Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory‐based approaches to the implications for patient safety of this pressure towards independent working. Methods In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in‐depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Participants conceived that the pressure towards independence in clinical work originated in trainees’ desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. Discussion The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger’s situated learning theory suggests that giving attention to the ‘independent doctor’ ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al. ’s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high‐stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory‐based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Any feedback that is delivered will be interpreted through the filters with which the receiver views the world of practice, the feedback provider, and his/her own abilities.
“any feedback that is delivered will be interpreted through the filters with which the receiver views the world of practice, the feedback provider, and his/her own abilities.”
From Factors influencing responsiveness to feedback: On the interplay between fear, confidence, and reasoning processes. (2012) · cites this paper as Kennedy et al. 2009
Cites
Wagner, H. R., Glaser, B. G., & Strauss, A. L. (1968) · Social Forces · doi:10.2307/2575405 · Cited by 46,470 · see citing works
Lincoln, Y. S., Guba, E. G., & Pilotta, J. J. (1985) · International Journal of Intercultural Relations · doi:10.1016/0147-1767(85)90062-8 · Cited by 45,787 · see citing works
Lave, J., & Wenger, E. (1991) · Cambridge University Press eBooks · doi:10.1017/cbo9780511815355 · Cited by 33,219 · see citing works
Handbook of qualitative research
Griffin, T. F. (1999) · Psychology and Marketing · doi:10.1002/(sici)1520-6793(199907)16:4 · Cited by 9,061 · see citing works
Ethnography: Principles in Practice
Stebbins, R. A., Hammersley, M., & Atkinson, P. (1985) · The Canadian Journal of Sociology · doi:10.2307/3340052 · Cited by 4,082 · see citing works
Risk management in a dynamic society: a modelling problem
Rasmussen, J. (1997) · Safety Science · doi:10.1016/s0925-7535(97)00052-0 · Cited by 2,994 · see citing works
The Significance of Saturation
Morse, J. M. (1995) · Qualitative Health Research · doi:10.1177/104973239500500201 · Cited by 2,663 · see citing works
Gaps in the continuity of care and progress on patient safety
Cook, R. I. (2000) · BMJ · doi:10.1136/bmj.320.7237.791 · Cited by 575 · see citing works
The paradoxes of almost totally safe transportation systems
Amalberti, R. (2001) · Safety Science · doi:10.1016/s0925-7535(00)00045-x · Cited by 484 · see citing works
Hawthorne effects and research into professional practice
Holden, J. D. (2001) · Journal of Evaluation in Clinical Practice · doi:10.1046/j.1365-2753.2001.00280.x · Cited by 263 · see citing works
Violations and migrations in health care: a framework for understanding and management: Figure 1
Amalberti, R., Vincent, C. A., Auroy, Y., et al. (2006) · BMJ Quality & Safety · doi:10.1136/qshc.2005.015982 · Cited by 228 · see citing works
Progressive Independence in Clinical Training: A Tradition Worth Defending?
Kennedy, T. J. T., Regehr, G., Baker, G. R., & Lingard, L. A. (2005) · Academic Medicine · doi:10.1097/00001888-200510001-00028 · Cited by 225 · see citing works
Self-citationClinical Oversight: Conceptualizing the Relationship Between Supervision and Safety
Kennedy, T. J. T., Lingard, L. A., Baker, G. R., Kitchen, L., & Regehr, G. (2007) · Journal of General Internal Medicine · doi:10.1007/s11606-007-0179-3 · Cited by 208 · see citing works
Self-citationPoint-of-Care Assessment of Medical Trainee Competence for Independent Clinical Work
Kennedy, T. J. T., Regehr, G., Baker, G. R., & Lingard, L. A. (2008) · Academic Medicine · doi:10.1097/acm.0b013e318183c8b7 · Cited by 203 · see citing works
Self-citationKennedy, T. J. T., Regehr, G., Baker, G. R., & Lingard, L. (2009) · BMJ · doi:10.1136/bmj.b128 · Cited by 188 · see citing works
Self-citationAgency, Modernity and Social Policy
Deacon, A., & Mann, K. (1999) · Journal of Social Policy · doi:10.1017/s0047279499005644 · Cited by 155 · see citing works
Vicente, K. J., & Christoffersen, K. (2006) · Theoretical Issues in Ergonomics Science · doi:10.1080/14639220500078153 · Cited by 114 · see citing works
‘Don't hesitate to call’– the underlying assumptions
Stewart, J. (2007) · The Clinical Teacher · doi:10.1111/j.1743-498x.2007.00141.x · Cited by 20 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Eva, K. W., Armson, H., Holmboe, E., Lockyer, J., Loney, E., Mann, K., & Sargeant, J. (2012) · Advances in Health Sciences Education · doi:10.1007/s10459-011-9290-7 · Cited by 402 · see citing works
The rotational approach to medical education: time to confront our assumptions?
Holmboe, E., Ginsburg, S., & Bernabeo, E. (2011) · Medical Education · doi:10.1111/j.1365-2923.2010.03847.x · Cited by 154 · see citing works
Bernabeo, E. C., Holtman, M. C., Ginsburg, S., Rosenbaum, J. R., & Holmboe, E. S. (2011) · Academic Medicine · doi:10.1097/acm.0b013e318212c2c9 · Cited by 152 · see citing works
Identifying coaching skills to improve feedback use in postgraduate medical education
Armson, H., Lockyer, J. M., Zetkulic, M., Könings, K. D., & Sargeant, J. (2019) · Medical Education · doi:10.1111/medu.13818 · Cited by 115 · see citing works
- Authors
- Kennedy, T. J. T., Regehr, G., Baker, G. R., & Lingard, L. A.
- Affiliations
- University Health Network (CA)
- University of Toronto (CA)
- Corresponding author
- Kennedy, Tara J T
- Venue
- Medical Education
- Publisher
- Wiley
- Published
- 2009-06-22
- Volume
- 43
- Issue
- 7
- Pages
- 645-653
- ISSN
- 0308-0110 (ISSN-L)
- 1365-2923
- OpenAlex
- W2091049030
- Cited by
- 141
- References
- 18
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 8 · 2023: 5 · 2022: 6 · 2021: 11 · 2020: 14 · 2019: 12 · 2018: 11 · 2017: 12 · 2016: 6 · 2015: 8 · 2014: 13 · 2013: 4 · 2012: 12
- FWCI
- 9.06
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Medical Education (publishedVersion)
- PubMed (publishedVersion)
- Scholarship@Western (Western University) (submittedVersion)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- medical trainees, professional autonomy, patient safety, teacher teams, help-seeking, situated learning, migration models, organisational pressures, workload, clinical supervision, internal medicine, emergency medicine
- MeSH terms
- Clinical Competence, Decision Making, Education, Medical, Graduate, Emergency Medicine, Humans, Internal Medicine, Internship and Residency, Ontario, Students, Medical, Safety Management, Qualitative Research
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
