Between the Accreditation Council for Graduate Medical Education's (ACGME) call for more stringent supervision standards and charges of improper amounts of resident supervision, Texas's Parkland Hospital's—resident supervision is a hot button issue for hospitals.
Supervision is a fundamental principle of medical education, but it hasn't been a focus of accreditation, educational, professional, or governmental organizations' standards until recently. The lack of attention means that residents may not be receiving appropriate supervision during training.
“Supervision really requires attending physicians to be proactive in providing supervision, and residents understanding and appreciating that role and seeking supervision,” Jeanne M. Farnan, MD, MHPE, assistant professor of medicine at the University of Chicago explains.
Faculty usually are not trained on how to provide proper supervision, making it even more important to encourage residents to actively seek help when they need it, says Vineet M. Arora, MD, MA, assistant professor of medicine, internal medicine associate program director, and assistant dean for curricular innovation at the Pritzker School of Medicine and the University of Chicago.
The following are reasons why residents feel uncomfortable contacting their attending physicians:
- Concern over revealing a knowledge gap. Residents fail to call because they're afraid the attending physician will think that they're not as smart as their peers, and they are hesitant to admit that they do not know something. Both attending physicians and residents must view uncertainty as an impetus for the resident to reach out to the supervisor, Farnan says.
- A desire to make decisions on their own. “Often, calling an attending and asking a question will interfere with the resident's own decision-making style and their own processing of the case,” Farnan explains. Residents want to talk to the attending physician about the case without having their clinical decision-making influenced by the attending physician.
Perception that the attending physician does not want to be called. Attending physicians often communicate a call-me-but-don't-call-me message to residents, which prevents residents from reaching out. “An attending will say, 'Here's my pager and my cell phone. Call me anytime, but I'm going to be at a dinner,' ” Farnan says. “Clearly that sends a message of 'Don't call me.'" Not answering calls or pages or chastising residents for calling also lessens the likelihood residents will reach out when they need help.
Attending physicians must take steps to facilitate supervision, but they need training and support from program leadership.
“People assume that you graduate from residency and you know how to be a good supervisor. Sometimes that's the case, and sometimes it's not,” Arora says.
The following tips will help faculty members become better at providing supervision and also eliminate many of the barriers residents face when asking for help:
Set clear expectations up front. Specifically outline in what circumstances you want the resident to notify you about a patient's condition. For example, Farnan tells residents that she wants them to call her anytime an end-of-life decision arises, or when a patient suffers an adverse event, dies, or goes to the ICU. Residents write these instructions on the sign-out sheets, and Farnan receives calls from the cross-cover residents caring for her patients, too.
Also, establish a time every night at which the resident will call you, such as 10 p.m. Recognize that residents get busy and may forget to call. If that is the case, attending physicians should take responsibility and page the residents, Arora says.
Be available. Attending physicians should answer all calls while on service. Some attending physicians may think that not responding or not providing residents guidance when asked promotes trainees' autonomy, but that's not the case. Instead, absentee attendings often cause residents to feel abandoned, Arora says.
Address uncertainty. Faculty members should assure residents, especially junior trainees, that uncertainty is part of education and they should not feel bad about asking for help.
Faculty members should also be aware of when residents feel the most uncertain, such as during rapidly escalating situations when many decisions must be made in a compressed time frame, and let residents know that it's okay to call during those high-stress encounters, says Farnan.
Tailor supervision. A one-size-fits-all approach does not apply to supervision, Arora says. Faculty members need to do some reconnaissance work up front and tailor their approach in order to provide appropriate supervision. Attending physicians should consider the learner's background and determine what his or her needs are.
Make discussions worthwhile. Conversations should be a back-and-forth dialogue between the resident and attending physician. Because few attending physicians have formal training in being a supervisor, they may tend to overmanage and not cultivate the resident's clinical decision-making skills.
Focus on patient safety. Because residents can sometimes resent supervision, program leaders and attending physicians should focus on patient safety when supervising trainees. “We tell residents that part of learning about patient safety is working on a team, and part of working on a team is communicating with your attending and others on team,” Arora says.
Julie McCoy is associate editor for the residency market. For more residency-related news, click here.
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
