Supervision and Autonomy in GME : *Watching

Report
Supervision and Autonomy in
GME : “Watching closely at a
distance”
SHC, Department of GME
Program Directors’ Education
Lunch Meeting
Sept . 9, 2010

“Supervision is more important than [duty]
hours” Dr. Bertrand Bell, 2009
Discussion Points
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What is supervision?
ACGME old and new regulations for
faculty supervision
How do we measure supervision?
What do we know about resident
supervision from the literature?
Legal standards for resident supervision
SUPERVISION
2003

The program must
ensure that qualified
faculty provide
appropriate supervision
of residents in patient
care activities.
2011
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Residents and attending should inform patients of their role in
the patient’s care
Faculty functioning as supervising physicians should delegate
portions of that care to resident physicians
Senior residents or fellows should serve in a supervisory role of
junior residents
The privilege of progressive responsibility in patient care
delegated to each resident must be assigned by the program
director and faculty
The resident is responsible for knowing the limits of his/her
scope of authority
Programs must set guidelines for circumstances and events
where residents must communicate with appropriate supervising
physicians
Faculty supervision assignments should be of sufficient duration
to assess the knowledge and skills of the resident and delegate
the appropriate level of patient care authority and responsibility.
In particular, during the PGY 1 year, residents must have
supervision level 1 or 2a (see below)
Levels of Supervision. In the development and description of
systems to oversee resident supervision and graded authority
and responsibility, each program must use the following
classification of supervision.

Direct Supervision —The supervising physician is
physically present with the resident and patient

Indirect Supervision:

Direct supervision immediately available – The
supervising physician is physically within the confines
of the site of patient care, and immediately available
to provide Direct Supervision

Direct supervision available – The supervising
physician is not physically present within the confines
of the site of patient care, is immediately available
via phone, and is available to provide Direct
Supervision

Oversight-The supervising physician is available to provide
review of procedures/encounters with feedback provided
after care is delivered.
But we always supervise… or at
least we think that we do!
The changes in supervision are not only
operational… they are also changes in
accountability for supervision policies,
measurement and documentation of
supervision.
2010 House Staff Survey
Supervision


to watch over so as to maintain order, etc
“the provision of guidance and feedback on
matters of personal ,professional, and
educational development in the context of
providing safe and appropriate care” (Butters J,
“Legal Standards of Conduct for Students and Residents : Implications
fir Health Professions Educators”, ACAD Med 71, 583)
Aims of Supervision


To promote professional development
To ensure patient safety
Implications of Supervision

Patient Safety


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Medical Education

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Preventing averse outcomes
Limiting institutional liability
Train competent physicians
Re-imbursement

HCFA/CMA guidelines
SUPERVISION – 2011 (1 of 4)



Residents and attendings should inform patients of
their role in the patient’s care
Faculty functioning as supervising physicians should
delegate portions of that care to resident physicians
Senior residents or fellows should serve in a
supervisory role of junior residents
SUPERVISION – 2011 (2 of 4)


The privilege of progressive responsibility in patient care
delegated to each resident must be assigned by the
program director and faculty (job descriptions on
MSO)
The resident is responsible for knowing the limits of
his/her scope of authority (job descriptions on MSO)


Job descriptionfs on MSO-NET are
decigned to eet Joint commission
Standards (not ACGME)
Our suggestion is to build on these
aviallbe job descritions
JOB DESCRIPTION: MDCRT-Critical Care Medicine Fellowship
Competencies,
Norm Rizk, MD, Program Director
Competencies define procedures or activities that the resident/clinical fellow can usually perform without on site supervision: Patient
management, including H&Ps and diagnostic and therapeutic treatments, procedures and interventions encompassing the areas
described below and similar activities. The underlying patient condition and complexity of the procedure might dictate the need for direct
supervision and physical presence of the attending physician. Whenever a question arises about resident/clinical fellow competency to
perform a procedure independently, the attending physician should be consulted.
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F1 First Year Critical Care Medicine Fellow
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Airway management, stable/unstable, trauma: Adult
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Arterial line -insert and remove: Adult
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Blood gases (arterial): Adult
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Cardiopulmonary resuscitation - closed: Adult
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Cardioversion: Adult
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Defibrillation: Adult
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Drug administration - intravenous: Adult
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Endotracheal suctioning: Adult
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Endotracheal/nasotracheal intubation: Adult
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Foley catheter - insert and remove: Adult
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Gastric lavage: Adult
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Laryngoscopy: Adult
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Lumbar puncture: Adult
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NG tube - insert and remove: Adult
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Other resuscitation: Adult
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Paracentesis/acute PD catheter: Adult
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Perform/interpret lab tests (spin Hct/do,UA/EKG/gram stain/peripheral smear/etc.): Adult
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Phlebotomy (including blood cultures): Adult
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Pulmonary artery catheter - insert and remove: Adult
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Thoracentesis: Adult
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Venous line - insert and remove: Adult
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___________________________________________________ __________________
Program Director
Date
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___________________________________________________ __________________
Resident/Clinical Fellow
Date
Current Status
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F1 First Year Critical Care
Medicine Fellow
Detailed description of
procedures
Whenever a question
arises about
resident/clinical fellow
competency to perform a
procedure independently,
the attending physician
should be consulted

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Only procedurally
oriented
Does not inform the
resident when to call for
help
Question from whom ?
SUPERVISION – 2011 (3 of 4)
Programs must set guidelines for
circumstances and events where residents
must communicate with appropriate
supervising physicians. (Where is this?)
 Faculty supervision assignments should be
of sufficient duration to assess the
knowledge and skills of the resident and
delegate the appropriate level of patient
care authority and responsibility. (what is
sufficient – by specialty?)

Standards under old ACGME
policies
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Policy on Supervision Surgical supervision: All surgical cases are adequately
supervised by qualified faculty; the level of supervision is at the discretion of the
faculty member. The intensity of the resident supervision reflects graduated
levels of responsibility based on individual skill and level of training. Clinical &
outpatient experience: Residents are given the opportunity to see patients,
establish provisional diagnoses, and initiate preliminary treatment plans within
the framework of the outpatient clinics. Particular emphasis is placed on ensuring
an opportunity for follow-up care of surgical patients, so that the results of
surgical care may be evaluated by the resident. Faculty supervision is provided
for outpatient clinics at all times. Hospital-based experience: Residents actively
participate in the management of patients in the perioperative period, both in the
intensive care and the non-acute patient care units. Frequent consultation with
faculty members is an essential part of excellent clinical care and optimizes
resident teaching. Supervision is provided for all inpatient consults. Scholarly
pursuits: Each resident is provided a timeline for his/her research rotation to
develop a research project that follows a format similar to NIH-R01 applicants.
Resident research is not limited to the research block in the PGY-3 year and
residents are encouraged to work with faculty on clinical research projects as
they arise. Personal growth: At the start of the residency, each resident is
assigned a faculty mentor. The resident should consult this individual for issues
that may arise during residency, including personality issues related to faculty or
fellow residents, performance issues, social issues, or general questions
regarding the residency and their growth. The faculty mentor reports to the
director of the residency program.
Current Status
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Surgical supervision
Clinical & outpatient
experience
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All surgical cases are
adequately supervised by
qualified faculty; the level
of supervision is at the
discretion of the faculty
member
Faculty supervision is
provided for outpatient
clinics at all times.
SUPERVISION – 2011 (4 OF 4)
•
•
In particular, during the PGY 1 year, residents must have supervision level 1
or 2a (see below)
Levels of Supervision*. In the development and description of systems to
oversee resident supervision and graded authority and responsibility, each
program must use the following classification of supervision.
1.
Direct Supervision —The supervising physician is physically present with
the resident and patient
2.
Indirect Supervision:
a.
Direct supervision immediately available – The supervising physician
is physically within the confines of the site of patient care, and
immediately available to provide Direct Supervision
b.
Direct supervision available – The supervising physician is not
physically present within the confines of the site of patient care, is
immediately available via phone, and is available to provide Direct
Supervision
3.
Oversight-The supervising physician is available to provide review of
procedures/encounters with feedback provided after care is delivered.
*VA 2005 Consensus Definition
Autonomy (the other side of the
coin)
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independence or freedom, as of the will or
one's actions
“Need to take increasing ownership of patient
assessment , clinical reasoning patient care
and outcomes”
Tensions between Supervision and
Autonomy
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For the medical
educator
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Imperative for quality
care but
There is also the need
to grant graduated
autonomy to learners
(desire to make
decisions on their
own)
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For the resident :
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Resident remains
responsible for his or
her diagnostic and
treatment decisions
but
Faculty oversight and
guidance to maintain
quality of patient care
(concern over
revealing a knowledge
gap)
Supervision is the social contract
between faculty and resident

The balance is achieved through entrustment of
the resident with specific professional activities
at specific levels (O. ten Cate , 2010)
1.
2.
3.
4.
5.
No entrustment
Service provision under close supervision
Limited supervision
Acting independently
Supervising others
Ensuring the quality of supervision
is the responsibility of :
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Clinical faculty
Residents
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Others
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PD
Regulatory bodies
Accreditation agencies
Consumer groups and
US judiciary
Supervision is both Procedural and
Cognitive
Monitor v. Measure
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Monitor: is this happening ?
Measure: How well is this happening?
How do we measure supervision?
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Qualitative Components
Quantitative Components
Qualitative / Quantitative Measurement
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Resident Surveys/Program Evaluations
Qualitative Components of
Supervision
Providing helpful feedback to residents
Availability of attending
Stimuli to learning
Professionalism/ Interpersonal skills
Presence
Treatment/Care Planning
Autonomy
Quantitative Components
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Time with resident :
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Direct contact with patient by attending
Direct contact with resident contributing to
decision making and care plan
Direct contact with resident giving feedback
Both qualitative and quantitative measures of
supervision have adequate to good
psychometric characteristics (one is not
necessarily better than the other )
What do we know about supervision
from residents and attendings?
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Early in training
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Residents generally overestimate the level at which
they can perform (some exceptions)
Attendings generally underestimate the level at which
residents can perform
Both reach equilibrium late in training
The higher acuity of the patient makes even
late in training residents ask for supervision
Suggesting additional considerations which
impact quality and time for supervision
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Trainee Considerations :
 Trainees working proficiency
 Quality of the treatment plan presented
 Trainee’s learning curve (as understood by
supervisor)
 Level of training
 Trainee's self confidence
 Trainee’s awareness of limitations
 Lack of acquaintance of supervisor with trainee
Supervisor Considerations
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Supervisors’ general experience
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more experienced supervisors allow more
autonomy
Balance of perceived supervisory role
between patient responsibility (Care
Provider) and resident education (Clinical
Educator)
Legal Standards
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Residents are held, in general, to the same
standard of conduct as a practicing professional
Supervising faculty may be found negligent if
the level of supervision is insufficient (McCough
v. Hutzel Hospital, 225 ILCS 60) “It is their
(specialists) advanced learning that enables
them to judge the competency of the resident’s
performance”
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includes authorization of treatment plan,
presence/availability at time of procedure
Circumstantial Considerations
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Quality of the team to assist the trainee
Type of activity (high risk vs. low risk)
Acuity of the patient
Time of day
Next Steps
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Individual RRC’s are now formulating
guidelines
Need for new program specific supervision
policies
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PGY Level Specific
Knowledge, skills, attitudes (competency
based)
Explicit supervisory role of the attending
Example
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UTHSC Graduate Medical Education:
Resident Supervision Policy

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