March 2016: Improve Patient Safety by Reassessing Your Supervision of Medical Trainees

Publication Quarter: 
Winter 2016

The relationship between clinical supervision and patient safety is well established, with numerous studies demonstrating a positive relationship between enhanced clinical supervision of medical trainees and improved patient outcomes. However, effective clinical supervision remains elusive in many health care organizations because of a variety of factors, including entrenched hierarchical structures, senior physicians who themselves were never trained to successfully manage others, or—notwithstanding efforts to foster a just culture—the persistence of individuals who do not encourage residents and junior physicians to escalate concerns, as they fear being criticized. 

The failure to effectively escalate concerning clinical situations can lead to otherwise avoidable adverse outcomes and, in turn, legal claims. This month's tip examines ways in which clinical supervision of junior physicians and medical trainees can be enhanced to promote greater patient safety, and potentially reduce adverse outcomes and legal claims. 

Clinical Supervision and Patient Safety 

Ever since the Libby Zion case made headlines in 1984, the health care industry has grappled with the need to improve patient safety in training environments while providing medical students and residents with enough autonomy to become highly skilled, independent physicians in their own right. Despite ongoing efforts to promote enhanced supervision, residents and attending physicians still possess very different perspectives as to what that means. For instance, a 2012 study by a team from the Loma Linda University School of Medicine found "clear and substantial differences between the perceptions of resident and attending physicians" as to when the supervising attending should be notified during commonly encountered clinical scenarios. This study concluded that "attending physicians reported they would want more frequent communication and closer supervision than routinely perceived by resident physicians." 

Why might attendings and residents perceive things so differently? In the Loma Linda study, residents did not interpret an attending's directive to "page me if you need me" as a mandate for open and frequent communication. Rather, it was interpreted by most residents who participated in the study as something akin to "don't call me unless you really have to." Similarly, a study of resident behavior conducted by a team from the University of Chicago noted that residents often failed to seek the attending physician's input because of "the existence of a defined hierarchy for assistance and fears of losing autonomy, revealing knowledge gaps, and 'being a bother.'" 

The systemic mistreatment of medical trainees in some programs also contributes to a culture in which those trainees are afraid to speak up about concerns or to escalate a case to a more senior physician. In the article "Legacy of Abuse in a Sacred Profession: Another Call for Change," published by the AMA Journal of Ethics in 2009, Dr. Janet Rose Osuch wrote: 

It is with difficulty that I articulate the often dominant teaching culture of our profession, which is adversarial and based on intimidation, public humiliation, harassment, belittlement, and fear, especially in the clinical years. ... Students are expected to know the answers to every "pimp" question without faltering, defer to the deeply entrenched hierarchical structure even in unfair situations, and never question their superiors, even when the latter are exhibiting overtly unprofessional behavior.

Improving Clinical Supervision 

What can attending physicians do to bridge the gap between their expectations and those of the residents they supervise?

The Journal of Graduate Medical Education article "SUPERB Safety: Improving Supervision for Medical Specialty Residents," by Shannon K. Martin, MD and Jeanne M. Farnan, MD, MHPE, offers a model that emphasizes a collaborative approach to clinical supervision. The SUPERB SAFETY model focuses on five characteristics that the authors consider crucial to effective supervision: 

1. Expectations are clear and established from the beginning of the relationship. 

2. Communication regarding new or active patients during the coverage period is planned, and both parties maintain easy availability. 

3. The impact of uncertainty on decision making is appreciated. 

4. Assistance is involved early when uncertainty is recognized. 

5. Clinical supervision requires different amounts of intensity for different learners and experiences, not "one size fits all." 

The following are the guidelines of the SUPERB SAFETY model:

Drs. Martin and Farnan also identified a number of short- and long-term activities that attending physicians can undertake to improve clinical supervision: 

How You Can Start TODAY: 

1. Identify supervision policies at your institution. 

2. Seek out existing faculty development opportunities to improve supervisory skills. 

3. Begin discussion with trainees about situations warranting attending-level contact. 

What You Can Do LONG TERM: 

1. Assist or lead improvements in institutional and program supervisory policies.

2. Create faculty development opportunities to improve critical supervisory skills such as direct observation. 

3. Involve trainees in the discussion and education about effective supervisory practices. 

4. Evaluate milestones toward progressive independence and readiness to supervise. 

Conclusion 

Despite significant efforts to improve clinical supervision throughout the health care delivery system, a disconnect still exists between the kind of supervision residents seem to want and need and the kind of supervision they may actually receive. FOJP acknowledges that culture change is difficult and takes time. Attending physicians can use the SUPERB SAFETY model to ensure that students and residents understand what is expected of them. Attending physicians should also regularly evaluate how they might be contributing to a culture in which fear of reprisal—rather than patient safety—drives a medical trainee's thought process when considering whether to seek help with a difficult case or to escalate a patient's care. Working to change the culture from one of fear to one of support will benefit everyone—especially the patients.