Barriers to achieving graduated responsibility: preparing pathology residents for independent practice

Allowing pathology residents to practice with high levels of autonomy helps prepare them for independent practice. The Accreditation Council for Graduate Medical Education (ACGME) recently added to the core requirements that residents must have opportunities to perform assigned clinical responsibilities under oversight supervision-defined as review and feedback after care is delivered. To understand the current state of resident autonomy, pathology residency programs were surveyed (32 responses) about the highest level of supervision achieved by senior residents for common pathology tasks, as well as the most significant barrier to achieving oversight supervision for each task. Each task was assigned a "supervision score" based on a weighted average of the supervision level achieved across programs. Barriers were grouped into common themes, such as "presumed patient impact," "billing/privileges," and "curricular structure." Although there was consensus around achievable supervision levels for some tasks (e.g., almost all programs allowed residents to gross with oversight supervision; none allowed residents to sign-out the final reports with oversight supervision), for most tasks, the level of supervision achieved and barriers to achieving oversight supervision varied widely across institutions. This study provides insights into the challenges programs face in providing opportunities for graduated responsibility to residents. The results also suggest programs can learn from each other to achieve oversight supervision in certain tasks. Opportunities to provide more graduated responsibility are explored to achieve the ACGME requirement of "oversight supervision" to better prepare residents for independent practice.