The dance between attending physicians and senior residents as teachers and supervisors.

OBJECTIVE To examine how attending physicians and senior residents negotiated shared responsibilities for teaching and supervising on clinical work rounds. METHODS As part of a larger ethnographic field study, we observed clinical work rounds on a General Pediatrics ward over 8 months, and interviewed 14 of 18 attending physicians and 9 of 11 senior residents whom we observed. Struck by the frequency of 2 codes in that data set ("stand back" and "step up"), we used the metaphor of a dance as an analytic strategy for understanding the dynamic relationship between attending physicians and senior residents. RESULTS Like a traditional dance with a priori choreography, and consistent with the traditional premise in graduate medical education, attending physicians frequently "stood back" and senior residents, accordingly, "stepped up" and took on teaching and supervising responsibilities. Less often, both attending physicians and senior residents assumed the lead, or attending physicians stepped up rather than entrust senior residents. The complex clinical context sometimes changed the choreography. Attending physicians and senior residents understood their mutual responsibilities but were not bound by them; they improvised to maintain high-quality patient care. CONCLUSIONS The metaphor of a dance enabled us to better understand not only how attending physicians and senior residents negotiate shared responsibilities for teaching and supervision on clinical work rounds, but also how the clinical context impacts this negotiation. A better understanding of this negotiated relationship may help to clarify assumptions and set realistic expectations for what it might take for senior residents to assume progressive responsibility for these responsibilities in today's clinical context.