'It's a cultural expectation...' The pressure on medical trainees to work independently in clinical practice.

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.

Preserving professional credibility: grounded theory study of medical trainees' requests for clinical support.

Objective: To develop a conceptual framework of the influences on medical trainees' decisions regarding requests for clinical support from a supervisor.

Design: Phase 1: members of teaching teams in internal and emergency medicine were observed during regular clinical activities (216 hours) and subsequently completed brief interviews. Phase 2: 36 in depth interviews were conducted using videotaped vignettes to probe tacit influences on decisions to request support.

Point-of-care assessment of medical trainee competence for independent clinical work.

Background: Clinical supervisors make frequent assessments of medical trainees' competence so they can provide appropriate opportunities for trainees to experience clinical independence. This study explored context-specific assessments of trainees' competence for independent clinical work.

Method: In Phase One, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews.

Questioning competence: a discourse analysis of attending physicians' use of questions to assess trainee competence.

Background: Attending physicians (APs) must constantly assess trainees' competence to act independently, to promote learning while ensuring quality of care. This study aimed to explore, through discourse analysis of case presentations, the process of competence assessment for case-specific clinical independence.

Method: Twenty-six case presentations in emergency medicine were observed and audiorecorded.

Clinical oversight: conceptualizing the relationship between supervision and safety.

Background: Concern about the link between clinical supervision and safe, quality health care has led to widespread increases in the supervision of medical trainees. The effects of increased supervision on patient care and trainee education are not known, primarily because the current multifacted and poorly operationalized concept of clinical supervision limits the potential for evaluation.

Objective: To develop a conceptual model of clinical supervision to inform and guide policy and research.

Making sense of grounded theory in medical education.

Background: Grounded theory is a research methodology designed to develop, through collection and analysis of data that is primarily (but not exclusively) qualitative, a well-integrated set of concepts that provide a theoretical explanation of a social phenomenon.

Objective: This paper aims to provide an introduction to key features of grounded theory methodology within the context of medical education research.

Overview: In this paper we include a discussion of the origins of grounded theory, a description of key methodological processes, a comment on pitfalls encountered commonly in the application of grounded theory research, and a summary of the strengths of grounded theory methodology with illustrations from the medical education domain.

Progressive independence in clinical training: a tradition worth defending?

Background: Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning.