Progressive Independence in Clinical Training: Perspectives of a National, Multispecialty Panel of Residents and Fellows

Background Progressive independence in patient care activities is imperative for residents' readiness for practice and patient safety of those cared for by graduates of residency programs. However, establishing a standardized system of progressive independence is an ongoing challenge in graduate medical education. Objective We aggregated trainees' perspectives on progressive independence, developed a model of the ideal state, and suggested actionable improvements. Methods A multispecialty, nationally representative group of trainees conducted a structured exercise that (1) described the attributes of an ideal system of graduated responsibility; (2) compared the current system to that ideal; (3) developed benchmarks to reinforce best practices; and (4) identified approaches to motivate programs to adopt best practices. Results At the core of an ideal model of graduated responsibility is a well-structured curriculum and assessment of individual learners using educational milestones and patient outcomes. The ideal model also includes robust faculty development and emphasizes faculty mentorship. To address legal and financial restrictions that pose barriers to progressive independent, objective outcome criteria like the milestones could be used to ask payers to alter payment restrictions for work performed by senior trainees, providing financial incentives for programs to encourage appropriate independent practice. Recognition of high-performing programs at the national level could motivate others to adopt best practices. Conclusions A multifaceted approach, incorporating robust 2-way feedback about skill level and autonomy between residents and faculty, along with improved faculty development in this area, is needed to optimize residents' attainment of progressive independence. There are incentives to move programs and institutions toward this optimal model.