The Helicoptering Attending: Diagnosis & management of supervisory micromanagement

Teresa M. Chan (@tchanmd)

As a clinician educator and educational leader, I recently read an article that really appealed to me; it is an article entitled: “The Micromanagement Disease: Symptoms, Diagnosis, and Cure” by Dr. Richard D. White.¹ In this article, White defines the more common usage of micromanagement as: “…the control of an enterprise in every particular and to the smallest detail, with the effect of obstructing progress and neglecting broader, higher-level policy issues.”¹

One of the challenges that creates this tension is trust.² Personally, I have always battled with the tension between needing to understand and support and… micromanagement. Whether this is in research or education, unfortunately, my doctor-brain comes to bear, and I want to get in there to diagnose the underlying problem. This leads me to get into the weeds with my team and can lead to a perception of me interfering with their job. And yet, sometimes, if I can do it right then I can provide new insights, as well as cognitive or emotional support that the team needs to get through a rough patch.²

There are a lot of analogies to one of my other day jobs as an academic leader as a clinical teacher of resident physicians. In this domain, I am an avid researcher, and have recently written an article about the tensions that clinical teachers face when supervising trainees. You see, when we emergency physicians are teaching a resident doctor, unlike Grey’s Anatomy, I am often right there with them in the room or nearby in an adjacent area within the emergency department. So, because we are so proximal to our trainees all the time, we have to navigate a tension between being a teacher/supporter sometimes, an assessor sometimes, and a patient protector.³

To explain this a bit more, as clinician educators are asked to be three things often at once.

First, we are our trainees’ teachers – resident physicians come into the emergency department to apprentice under me on shifts and to gain experience on the job. My job is to review their cases and provide guidance to them as they investigate, resuscitate, or counsel patients.

At the same time, we are currently in the midst of a vast transformation of postgraduate medical training into a form of education called Competency Based Medical Education ⁴. This form of outcomes-based education was first called for in the 1970s⁵, and has finally been implemented very recently in Canadian Emergency Medicine.⁶ Because of this shift in educational styles, as an attending physician I am asked to frequently assess and provide feedback to my trainees on their clinical shifts. Obligatorily, I must induce the Hawthorne effect so that I can directly observe their clinical care, give them feedback, and help advance their skills/knowledge.⁷

Finally, I must act as a patient protector. Afterall, we are the most responsible physician, and must ensure we protect the patients from errors and mistakes that a trainee may make since they are still learning the craft of being an emergency physician. In our study, we found that there was a subtype of behaviours called ‘helicoptering’ that teachers admitted to using – where due to their overlapping obligations of being an assessor and a patient protector, they hover to ensure that a trainee safely carries out patient care.³ This act of helicoptering is very analogous to what a micromanaging boss might do.²

The therapy for micromanagement is to shift from a position of mistrust to one where you can entrust those in your team. Thus, White (2010) suggests there are a few key ‘prescriptions’ for Micromanagement which are summarized in Figure 1.

Here is how I think can translate well into the clinical supervision of learners within CBME contexts:

1. Recognize that micromanagement is occurring – Do all members of your team have authority to make decisions appropriate to their level? Have talented trainees been given the chance to make decisions?^1,2
2. Promote people carefully – This is more for a competency committee chair or program director to consider, but it’s important to realize that promotion is an important task – and that simply completing all the tasks required at a certain training level (e.g. X number of entrustable professional activities or Y number of surgical cases) may not necessarily be the whole picture. Some individuals may thrive as junior residents but find it daunting to take on more responsibilities (e.g. chief resident roles)¹;
3. Clarify expectations – if supervisors are unclear about what their direct reports should do, then employees will often be unclear about what they should do, and therefore become dependent on the manager for insights into how they will be assessed^1,2. Use teaching tools like entrustable professional activities to engage your learners in a fruitful discussion around the expectations you have for them at their level of training;
4. Make it permissible to make mistakes – honestly, even when the stakes are life and death in the emergency department, we must find ways for our resident physicians to have enough room to make certain kinds of mistakes (the ones I can help fix!). As such, I fully endorse the idea that psychologically safe environment^8,9 where individuals are able to make mistakes and be supported through them are imperative for high functioning teams.
5. Flatten the hierarchy – creating an environment where everyone feels safe but also can speak up is key. Hierarchies can certain prevent this – we know this far too well within healthcare. There is an entire movement that seeks to abolish hierarchy to ensure patient safety so that nurses or healthcare aides feel free to speak up in a critical resuscitation when they see something going wrong. Similarly, within any organization it can be helpful to usher in a more equitable culture where everyone feels empowered to give each other feedback. Kegan and Lahey have previously written about deliberately developmental organizations¹⁰, which help us to push
6. Change from micromanagement to leadership or mentorship – As a clinical supervisor, it is important when working with more senior trainees to delegate authority, rather than tasks. Leadership-Member exchange theory shows that increase supervisor listening can also be helpful.¹¹ Supporting direct reports thorough active listening, and then joint solution finding, rather than simply stepping in to solve their problems is a key to being a good attending in the age of CBME.²

For teachers interested in supporting trainees via CBME, I hope this blog post helps you to recognize and manage your own helicoptering tendencies when acting as a clinical supervisor. Remember, growth requires space; learning to stop helicoptering will help your trainees have space to learn and grow.

References

1. White RD. The Micromanagement Disease: Symptoms, Diagnosis, and Cure. Public Pers Manag. 2010;39(1):71-76. doi:10.1177/009102601003900105
2. Hernandez JS. Am I Directing or Micromanaging? Physician Exec. 2012;38(5):70-72.
3. Li SA, Acai A, Sherbino J, Chan TM. The Teacher, the Assessor, and the Patient Protector: A conceptual model describing how context interfaces with the supervisory roles of academic emergency physicians. AEM Educ Train. 2021;5(1):52-62. doi:10.1002/aet2.10431
4. Frank JR, Snell L, Englander R, Holmboe ES. Implementing competency-based medical education: Moving forward. Med Teach. 2017;39(6):568-573. doi:10.1080/0142159X.2017.1315069
5. McGaghie WC, Miller GE, Sajid AW, Telder TV. Competency Based Curriculum in Medical Education: An Introduction. Public Health Pap. Published online 1978.
6. Sherbino J, Bandiera G, Doyle K, et al. The competency-based medical education evolution of Canadian emergency medicine specialist training. Can J Emerg Med. 2020;22(195-102):1-8. doi:10.1017/cem.2019.417
7. Gottlieb M, Jordan J, Siegelman JN, Cooney R, Stehman C, Chan TM. Direct Observation Tools in Emergency Medicine: A Systematic Review of the Literature. AEM Educ Train. 2021;5(3):e10519. doi:10.1002/aet2.10519
8. Edmondson A. Psychological Safety and Learning Behavior in Work Teams. Adm Sci Q. 1999;44(2):350-383. doi:10.2307/2666999
9. Edmondson AC, Lei Z. Psychological Safety: The History, Renaissance, and Future of an Interpersonal Construct. Annu Rev Organ Psychol Organ Behav. 2014;1(1):23-43. doi:10.1146/annurev-orgpsych-031413-091305
10. Kegan R, Lahey LL. An Everyone Culture: Becoming a Deliberately Developmental Organization. Harvard Business Review Press; 2016.
11. Lloyd KJ, Boer D, Voelpel SC. From Listening to Leading: Toward an Understanding of Supervisor Listening Within the Framework of Leader-Member Exchange Theory. Int J Bus Commun. 2017;54(4):431-451. doi:10.1177/2329488415572778