Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation




Education Sciences

First Advisor

Dr. Ryan M. Crowley

Second Advisor

Dr. Zitsi Mirakhur


A growing concern in graduate medical education (GME), research indicates that some graduating residents are unprepared to enter unsupervised practice. The aim of this qualitative phenomenological study is to illuminate the resident experience surrounding the development of autonomy in clinical decision making relative to teaching practices. Research questions include: (1) What is the dual role of learner/teacher like for residents as they attend to their own and others’ development of autonomy in clinical reasoning and decision making? (2) Which teaching methods do they commonly experience as the learner and practice as the teacher relative to this development, and which methods are associated with experiences most and least valued for growth in autonomy? (3) How are these teaching methods acquired? (4) How do residents experience and interpret the provision of autonomy by supervising teachers?

The researcher obtained a purposive sample of eight participants from GME programs in a large public university in the south, representing residents in early training to post-training as chief residents, from the specialties of Internal Medicine, Pediatrics, and the combined specialties of Internal Medicine-Pediatrics and Internal Medicine-Psychiatry. The researcher conducted in-depth interviews supported by member checks and memos. Consistent with the phenomenological framework, In-Vivo and Process Coding enabled identification of meaning units and experiential themes. The interpretative phenomenological analysis (IPA) method was used to conduct data analysis.

Findings revealed that these residents experience difficulty and uncertainty in their dual role of learner/teacher, attaching meaning to the experience as an unsteady balance between the two roles. Despite this challenge, they particularly value their teaching role for their own learning and autonomy development. A lack of formal teaching training, however, means that residents rely on acquiring teaching practices through observation and imitation of others, often resulting in the adoption of underdeveloped or misaligned methods for teaching clinical reasoning. Teaching methods included the traditional apprenticeship methods of behavioral modeling, coaching and scaffolding early in the intern year, transitioning to cognitive apprenticeship limited to learner articulation of clinical reasoning, coaching, scaffolding and most often, modeling of the clinical decision or plan of care. Exceptional teaching for growth in autonomy was differentiated by modeling of the clinical reasoning process and a climate of psychological safety, often including self-directed learner reflection and exploration. All participants experienced a variable provision of autonomy, attributing the willingness of some faculty to grant autonomy to other factors besides patient needs and entrustment in resident ability, which may jeopardize the experience needed for unsupervised practice.

Digital Object Identifier (DOI)