Progressive independence in clinical training: a tradition worth defending?

BACKGROUND Progressive independence is a traditional premise of clinical training. Recently, issues such as managed care, work hours limitation, and patient safety have begun to impact the degree of autonomy afforded to clinical trainees. This article reviews empirical evidence and theory pertaining to the role of progressive autonomy in clinical learning. METHOD A computerized literature search was performed using Medline, PsycINFO, Social Sciences Citation Index, and Educational Resources Information Center. This article presents a synthetic review of relevant empirical and theoretical concepts from the domains of medicine, psychology, education, kinesiology, and sociology. RESULTS The clinical psychology and medical education literatures provide evidence that clinical trainees act more independently as their training progresses, but have not yet evaluated the educational efficacy of providing progressive independence, or the consequences of failing to do so. The expertise and motor learning literatures provide some theoretical evidence (as yet untested in complex clinical environments) that the provision of too much guidance or feedback to trainees could be educationally detrimental in the long term. The sociology literature provides insight into the cultural values underlying the behavior of clinical teachers and trainees relating to issues of supervision and independence. CONCLUSIONS There is limited empirical support for the current model of progressive independence in clinical learning; however, diverse theoretical perspectives raise concern about the potential educational consequences of eroding progressive independence. These perspectives could inform future research programs that would create a creative and effective response to the social and economic forces impacting clinical education.