Is More Supervision of Medical Residents Always Better for Patient Care?

MedicalResearch.com Interview with:
Kathleen M. Finn MD, MPhil
Christiana Iyasere MD, MBA
Division of General Internal Medicine
Department of Medicine
Massachusetts General Hospital, Boston

MedicalResearch.com: What is the background for this study?

Response: While the relationship between resident work hours and patient safety has been extensively studied, little research evaluates the role of attending supervision on patient safety. Beginning with the Bell Commission there have been increased calls for enhanced resident supervision due to patient safety concerns. At the same time, with the growth of the hospitalist movement more faculty physicians join daily resident work rounds under the assumption that increased supervision is better for patient safety and resident education. However, we know that supervision is a complex balancing act, so we wanted to study whether these assumptions were true. On the one hand patient safety is important, but on the other adult learning theory argues residents need to be challenged to work beyond their comfort level. Importantly, being pushed beyond your comfort level often requires appropriate space between teacher and learner. To investigate the role of attending supervision on patient safety and resident learning we studied the impact of two levels of physician supervision on an inpatient general medical team.

Twenty-two teaching faculty were randomized to either direct supervision of resident teams for patients previously known to the team vs usual care where they did not join rounds but rather discussed the patients later with the team. Faculty participated in both arms of the study, after completing the first arm they then crossed over to the other arm; each faculty member participated in the study for a total of 4 weeks.

MedicalResearch.com: What are the main findings?

Response: We found that there was no statistical difference in medical error rates, mortality, transfer to the intensive care unit or length of stay between the direct supervision vs usual care groups. A time motion study of time spent speaking during work rounds found first year residents spoke statistically less when the faculty member was on rounds though the length of rounds was unchanged. There was no difference in written orders, consults called or radiology studies ordered between the groups. In surveys residents felt rounds were less efficient, that they had less autonomy and less ability to make independent decisions when a faculty member was present on work rounds.   

MedicalResearch.com: What should readers take away from your report?

Response: Supervision is complicated and finding the right balance between patient safety, resident education and resident autonomy is important. In determining the level of appropriate supervision, this study suggests patient safety may not be compromised by giving residents more autonomy. In order to create competent physicians of the future, it is key to find the right balance between direct supervision and autonomy. This work suggests that residency programs should think about the individualized needs of their institution and residents in determining the appropriate level of supervision and not assume that more supervision is always better. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: This study only evaluated patient safety on inpatient internal medicine resident teams and was done only at one hospital. For larger generalizability this work should be repeated at multiple institutions. Overall, supervision and patient safety is an area ripe for additional studies in all types of settings. In addition, peer learning and how residents learn from each other on rounds without a faculty member present is an area of significant opportunity for ongoing research. 

MedicalResearch.com: Is there anything else you would like to add?

Response: We just wanted to reassure the lay audience who may be concerned about not having a senior physician on rounds. Even in the “control” arm, senior faculty saw the patients every day, reviewed their labs and studies and would discuss their care with the resident team.

The main difference was they gave the team some space to independently come up with a plan on their own that was then reviewed by the supervising physician.

Disclosure: This study was funded by the Edward J. Stemmler, MD Medical Education Research Fund of the National Board of Medical Examiners.

Citation: 

Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident EducationA Randomized Clinical Trial. JAMA Intern Med. Published online June 04, 2018. doi:10.1001/jamainternmed.2018.1244

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