In at the deep end: Psychosocial aspects of developing autonomy in histopathology training

Medical postgraduate trainees are given increasing levels of responsibility during training in the apprenticeship-model of training [1-3]. Responsibility is said to be a key driver of deep learning and understanding [4-7]. Trainees with greater levels of responsibility for decision making have higher levels of motivation to learn compared with trainees who self-assess as having less autonomy [5]. The Royal College of Pathologists (RCPath) indicate that ‘graded responsibility’ is part of training histopathologists and provided a framework for implementation with increasingly complex specimens suitable for reporting by more senior trainees [8,9].


Introduction
Medical postgraduate trainees are given increasing levels of responsibility during training in the apprenticeship-model of training [1][2][3]. Responsibility is said to be a key driver of deep learning and understanding [4][5][6][7]. Trainees with greater levels of responsibility for decision making have higher levels of motivation to learn compared with trainees who self-assess as having less autonomy [5]. The Royal College of Pathologists (RCPath) indicate that 'graded responsibility' is part of training histopathologists and provided a framework for implementation with increasingly complex specimens suitable for reporting by more senior trainees [8,9] .
Devolving diagnostic responsibility by trainers involves a complex series of holistic judgments [2,10]. There are no objective measurement tools that can aid this process either for trainers or trainees [11]. Trainers describe fear of litigation as a barrier to developing responsibility for patient management decisions and histopathology is no exception [12,13]. Four elements have been shown to effect the decision to devolve autonomy to perform discrete practical procedures; attributes of the trainee, the nature of the task, the supervisors and characteristics of the working environment [14]. These factors were also found in a similar study of anaesthetic trainees [11]. Dijksterhuis et al. found that depth of acquaintance with the trainee was most frequently cited as the variable affecting decisions to delegate work [14]. Ten Cate showed that trainee honesty and reliability were important factors in deciding whether they were ready to take on responsibility for entrustable professional activities (EPA's) [2,10]. Knowing how to deal with mistakes of oneself and others, having a sense of responsibility and being able to self evaluate and re lect were also highlighted as desirable characteristics of trainees [10].
Published research regarding graded responsibility in histopathology is limited. A recent qualitative study in the UK described perceived learning needs of histopathology trainees with respect to training content and structure [15]. These perceived requirements for safe and effective graded responsibility include having a variable and suf iciently large case load in early years of training, the ability to write clear and concise reports, being able to recognise normal histology and being given regular responsibility for presenting at multi-disciplinary team (MDT) meetings. Trainees also valued detailed discussion of microscopic morphology at the doubleheaded microscope with their senior colleagues as a necessary component of training to develop graded responsibility [15].
Two questionnaire based studies in the US both concluded that trainee exposure to responsibility in histopathology training was limited despite being perceived as making a positive contribution to developing diagnostic con idence [13,16]. This paper reports indings of a qualitative study of perceived learning needs of trainee histopathologists for graded responsibility with particular reference to non-technical skills around professionalism and developing resilience.

Methods
Grounded theory informs the qualitative study design of this research. Nine histopathology trainees took part in a focus group from a possible cohort of eleven. Participants were asked 'What do you perceive are the learning needs of histopathology trainees to develop skills for safe and con ident independent reporting in surgical histopathology?' Five interviews with consultant histopathologists were conducted after the focus group. The consultants were relatively new to their posts having been practicing in their roles for 2 months to 5 years. Iterative data collection methods were used to build on the emerging data themes. Consultant interviews were performed in addition to the trainee focus group in order to highlight any possible unperceived learning needs the trainees may have [17].
Data was recorded and transcribed into an anonymous format by the author. Data were analysed using an open coding framework. The author has irst-hand understanding of the social, cultural and professional contexts of the subject and its participants as a practicing consultant histopathologist who trained in the department from where the cohort of study participants originated. Data relating to professionalism and resilience are presented here. Participants gave informed consent to take part in the study and were allowed to withdraw at any time. This project was granted ethical approval by the Research Ethics Committee for the School of Postgraduate Medical and Dental Education, Cardiff University.

Results
Learning to manage ones time was a need that was identi ied by both trainees and consultants. Participants were concerned that graded responsibility would slow a trainee down; they worried about spending a greater amount of time looking at histological slides of a perceived simple specimen such as an in lamed appendix. However, an ST3 in the focus group noted that with accumulating experience their abilities in time management and prioritisation improved:

"...It's just something that clicked inside of me and my time management became so much better when I'd had a couple of years experience."
Overall, most consultants believed that it was possible to perform graded responsibility in a safe way as long as trainees consulted a colleague about anything they were unsure of and consultants appeared to trust trainee to do this: "...most trainees have common sense, if they see something unusual they will show someone, not report it themselves." Participants stated that diagnostic con idence in surgical histopathology reporting improves with time. Despite comments that graded responsibility is best commenced following the part 2 exam, someone did offer a different view with reference to building con idence in this area: "....if independent reporting is something that is started from the very beginning of histopathology training that con idence can be built up…built up…and built up to a stage actually maybe even earlier than I felt con ident." Some felt that passing part 2 of the Royal College of Pathology examinations had a positive effect on con idence: "Having the [part 2 FRCPath] exam gives you a certain level of con idence and before having the exam you almost felt as if there was something missing.... " There were repeated expressions of fear, stress and anxiety from both consultants and trainees with respect to the responsibility of independent reporting by trainees. Fear of making mistakes was frequently cited:

Discussion
Being able manage time effectively is a new learning need that is not mentioned by literature concerning autonomy in other medical training schemes. This may be something unique to histopathology with working patterns that are distinct from other medical disciplines. Studies have shown that a surgical histopathology case reported by a consultant can take a mean of between 5 and 10 minutes times with approximately 2.5 minutes per slide with variation between cases due to complexity and different number of slides per case [18]. No research data has been reported to our knowledge that compares trainee with consultant reporting time during a time of transition to increasing responsibility. The theme of time management is intimately linked with the psychosocial need to feel con ident about the content of the report issued and with the need to avoid the fear associated with missing a clinically important diagnosis.
There is an apparent perceived con lict between aspects of training in histopathology are deemed to be useful learning experiences and those processes that are necessary for providing a service to patients and clinicians and this is a phenomenon documented across medicine [19,20]. Although not stated explicitly, there was a concern that introduction of graded responsibility into training was a way of getting more direct service provision out of trainees and that this would likely revolve around simple specimens of little educational value.
Ensuring patient safety is clearly an important part of all postgraduate medical training schemes. Guaranteeing safety is often cited as a reason for not devolving responsibility. 21 Some authors assert that the likelihood of a trainee making an error is very low [22,23]. However, the reality may be very different. Error rates in pathology are estimated at between 1 and 43% of surgical specimens [24]. A UK study found that 58% of consultant respondents self-reported making an error and 42% of those were thought to have had a clinical impact [25]. Participants in this study only referred to "personal cognitive" errors which can be reduced by having colleagues on hand for a second opinion [26]. None of the participants in this study made reference to the potential for errors occurring by chance, biopsy sampling or due to laboratory systems failure.
The experience of Dutch anaesthetic and obstetrics and gynaecology trainees is that ultimate responsibility for patients' outcomes lies with the consultant or supervisor [10,11]. This was also expressed in our our study. However, trainee histopathologists have joint responsibility for the content of reports generated under supervision of their trainers and litigation would be defended by health boards providing medical indemnity for their employees. Trainees should be encouraged to audit their own performance and take responsibility for their input into histopathological reports.
When devolving responsibility to a trainee, studies have shown that supervisors put considerable weight on a trainees' self-assessment of whether they were competent to perform a particular task before granting them independence to do it without supervision [14]. This may be ill-judged if one considers how poor performers are apt to over-estimate their abilities [11,27]. Furthermore, trainees have been shown to put on an overly con ident presentation of themselves to give an impression of credibility when they may feel unsure of themselves [28].
There is evidence that more responsibility is granted to trainees when on-call out of hours [11,14,21,29] and whilst this is also true of other pathological specialties such as microbiology [30]. Surgical histopathology trainees are not given on-call duties in most training centres [30]. Trainees need to develop self-awareness and know when their limitations have been reached as this will prompt feedback seeking behavior [31,32]. Building in re lective practice into histopathological training could be a solution to address this learning need and help trainees explore their own beliefs and emotions about graded responsibility. It may help individuals to discover what it is that creates obstructions to independent practice, be they tangible or imagined [33][34][35]. Re lective practice may generate an enhanced sense of self-awareness and help trainees to be aware of their own limitations and characterise them more fully [33][34][35][36]. Diagnostic limitations are likely to be a very individual characteristic based on individual experience. As such, knowing ones limitations is a learning need that cannot be addressed and taught by another individual.
Developing experience and diagnostic con idence by trainees appear to be closely linked. These characteristics are thought to allow for smoother transition to independence [16]. This may be further enhanced by increasing the amount of re lective practice by trainees. Many authors state that re lective techniques can lead to improved con idence in the workplace [33][34][35].
Interestingly, it may be that enhanced self-esteem and con idence may result from introduction of graded responsibility. Graded responsibility may induce a positive feedback cycle of responsibility leading to increased morale leading to greater motivation and then more responsibility seeking behaviour. Editorial opinion in the literature supports this idea [13,23]. Also, there is evidence to substantiate these claims in other medical disciplines. Perceived self-esteem has been shown to increase with enhanced levels of responsibility in general practice trainees [37].
To enable graded responsibility during training one needs to mitigate against high levels of anxiety as this can lead to an inhibition of learning known as "destructive friction" [38]. Having said this, many authors believe a little bit of stress is necessary for deep and sustained learning and that this applies to histopathology trainees [13]. This concept is allied to Vygotsky's educational theory of the "zone of proximal development" where deep learning is said to occur when people place themselves just beyond their competency level and, under guidance from a more experience facilitator, develop new skills and knowledge [8].
We see from our data that some perceive responsibility in histopathology reporting as being onerous particularly when it comes as an abrupt transition following training. So, as with the need to increase con idence, coping with stress may also be made easier as a result of graded responsibility as well as being a requirement before engaging with it. Trainees need to be supported to cope with uncertainty and worries about making mistakes. Peer support groups may offer a solution to this and are, perhaps, an organisational requirement for histopathology doctors in-training. A peer supervision quartet, for example, is a way for small groups of trainees to give helpful feedback to one another on a semi-formal basis to tackle personal and managerial issues that can arise during training [39].
An open organisational culture has been shown in the literature to be a central article required for effective learning to take place [40,41]. Kennedy et al state that supervisors who are approachable and available to trainees tend to promote an open organization culture in which trainees feel able to ask for assistance without fear of ridicule [32].

Conclusion
Trainees provided valuable insight into the lived reality of developing autonomy in histopathological reporting. It is clear there are anxieties that need to be respected and addressed. Ensuring that trainees are supported within a training environment responsive to training needs may ease the psychological burden. Different levels of guidance and support will be necessary to re lect trainees' variable rate of progress along the path to expertise 42 and identifying these differences is a key challenge for supervisors. Providing time for case reviews with re lection is likely to aid development of skills and resilience to tackle increasing levels of responsibility and forms a central aspect of medical professionalism.

Competing interests
A Finall received a career development fund from the Association of Clinical Pathologists (ACP) in support of a Masters degree in Medical Education.