title: Attending physician variability: a model of four supervisory styles.
abstract: OBJECTIVE
  There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities.
  
  
  METHODS
  Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review.
  
  
  RESULTS
  Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees' progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team.
  
  
  CONCLUSIONS
  The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.
authors.affiliation: M. Goldszmidt is associate professor, Department of Medicine, Division of Internal Medicine, and associate director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. L. Faden is research specialist and education coordinator, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada. T. Dornan is professor of medical education, Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands. J. van Merriënboer is professor of learning and instruction and research program director, Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, the Netherlands. G. Bordage is professor, Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois. L. Lingard is professor of medicine and director, Centre for Education Research & Innovation, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
authors.forename: Mark
authors.initials: M
authors.lastname: Goldszmidt
authors.forename: Lisa
authors.initials: L
authors.lastname: Faden
authors.forename: Tim
authors.initials: T
authors.lastname: Dornan
authors.forename: Jeroen
authors.initials: J
authors.lastname: van Merriënboer
authors.forename: Georges
authors.initials: G
authors.lastname: Bordage
authors.forename: Lorelei
authors.initials: L
authors.lastname: Lingard
mesh_terms: D002983:Clinical Competence; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007400:Interprofessional Relations; D007407:Interviews as Topic; D008505:Medical Staff, Hospital; D017145:Models, Educational; D009864:Ontario; D010348:Patient Care Team; D010819:Physician's Role; D013663:Teaching