Evolving Conceptualizations of Autonomy: A Longitudinal Study of Pediatric Hospital Medicine Fellows into Attending...

Promoting autonomy while ensuring appropriate supervision is a characteristic tension in graduate medical training. How autonomy is conceptualized through time, during the transition from trainee to attending, is not well understood. Thus, supervisors and trainees may have misaligned expectations for autonomy across the training continuum. This longitudinal qualitative study asked, "How do trainees conceptualize and enact autonomy through training and into clinical practice as attendings?"

We recruited fourteen first-year pediatric hospital medicine fellows in July 2021 for a three-year study. We conducted semi-structured, recursive interviews approximately every six months. Transcripts were coded through an iterative process, and themes constructed by reviewing coded data and identifying patterns within and across longitudinal narratives.

Participants' conceptualization and enactment of autonomy shifted from that of complete independence to a dynamic, collaborative model. This shift often occurred during fellowship or after transition to the attending role. As fellows, participants valued independent rounding because it fostered a sense of ownership and volitional decision making, reinforcing their sense of autonomy. As new attendings, many struggled to reconcile this prior valuation of independence with their discomfort granting similar independence to trainees. Because independence and autonomy had become tightly intertwined in their thinking, new attendings approach autonomy as conditional when trainees demonstrated readiness.

Fellows' conceptualizations and enactments of autonomy evolved across training and into unsupervised practice, underscoring its developmental, temporal nature. Recognizing how the meaning of autonomy evolves may help align trainee-supervisor expectations and support intentional approaches to fostering autonomy across the training continuum.