• Andrea Gingerich, Rose Hatala, and Tristen Gilchrist.
• Division of Medical Sciences, University of Northern British Columbia, British Columbia, 3333 University Way, Prince George, V2N 4Z9, Canada. Andrea.Gingerich@unbc.ca.
• J Gen Intern Med. 2024 Oct 25.

BackgroundIndirect supervision is essential for granting autonomy to learners. Sometimes referred to as leaving the learner "unsupervised," there is growing recognition that learners and supervisors engage in clinical support through ongoing interactions, albeit at a distance.ObjectiveTo understand how the complementary activities of asking for and providing clinical support at a distance come together as indirect supervision by identifying the natural language used between learners and supervisors.DesignA collective case study of 15 attending physician-senior medical resident dyads from 2018 to 2023. Each case consisted of 2 full days of ethnographic observation of the resident on an internal medicine clinical teaching unit in one of three metropolitan hospitals; 2 end of day interviews with each dyad member; and a third interview with the attending after the 2-week rotation.ParticipantsFifteen internal medicine residents (PGY-2 and PGY-3) who were scheduled to work for the first time with 15 attending physicians.ApproachData collection was iterative with deductive and inductive analysis to identify patterns of communication.Key ResultsThe language of "checking," such as checkpoints, checking on, and checking in, was central to communications within dyads. Indirect supervision included attendings using scheduled checkpoints and backstage oversight activities to check on the senior resident's patient care while expecting residents to access their support, as needed, by checking-in with them. Residents checked in with their attending to relay patient information updates, ask questions, and hint at needing their plans doublechecked; these communications had similar formats making them difficult to distinguish but functioned to preserve resident independence while accessing clinical support.ConclusionsIndirect supervision creates clinical support through ongoing communication between learners and supervisors at a distance. It is a collaborative process for mutual reassurance that safe patient care is being provided and that support is available when needed.© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.

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