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 What is supervision? What is supervision? ACGME old and new regulations for faculty supervision ACGME old and new regulations for faculty supervision How do we measure supervision? How do we measure supervision? What do we know about resident supervision from the literature? What do we know about resident supervision from the literature? Legal standards for resident supervision Legal standards for resident supervision

SUPERVISION The program must ensure that qualified faculty provide appropriate supervision of residents in patient care activities. The program must ensure that qualified faculty provide appropriate supervision of residents in patient care activities. Residents and attending should inform patients of their role in the patient’s care 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 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 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 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 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 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. 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) 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. 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 Direct Supervision —The supervising physician is physically present with the resident and patient Indirect Supervision: 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 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 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. 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 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) “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 Preventing averse outcomes Limiting institutional liability Medical Education 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 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 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 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 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) 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. F1 First Year Critical Care Medicine Fellow Airway management, stable/unstable, trauma: Adult Arterial line -insert and remove: Adult Blood gases (arterial): Adult Cardiopulmonary resuscitation - closed: Adult Cardioversion: Adult Defibrillation: Adult Drug administration - intravenous: Adult Endotracheal suctioning: Adult Endotracheal/nasotracheal intubation: Adult Foley catheter - insert and remove: Adult Gastric lavage: Adult Laryngoscopy: Adult Lumbar puncture: Adult NG tube - insert and remove: Adult Other resuscitation: Adult Paracentesis/acute PD catheter: Adult Perform/interpret lab tests (spin Hct/do,UA/EKG/gram stain/peripheral smear/etc.): Adult Phlebotomy (including blood cultures): Adult Pulmonary artery catheter - insert and remove: Adult Thoracentesis: Adult Venous line - insert and remove: Adult ___________________________________________________ __________________ Program Director Date ___________________________________________________ __________________ Resident/Clinical Fellow Date

Current Status 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 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?) 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?) 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 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 Surgical supervision Clinical & outpatient experience 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) 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. 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) independence or freedom, as of the will or one's actions 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” “Need to take increasing ownership of patient assessment, clinical reasoning patient care and outcomes”

Tensions between Supervision and Autonomy For the medical educator For the medical educator Imperative for quality care but Imperative for quality care but There is also the need to grant graduated autonomy to learners (desire to make decisions on their own) There is also the need to grant graduated autonomy to learners (desire to make decisions on their own) For the resident : 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) The balance is achieved through entrustment of the resident with specific professional activities at specific levels (O. ten Cate, 2010) 1. No entrustment 2. Service provision under close supervision 3. Limited supervision 4. Acting independently 5. Supervising others

Ensuring the quality of supervision is the responsibility of : Clinical faculty Clinical faculty Residents Residents Others Others PD PD Regulatory bodies Regulatory bodies Accreditation agencies Accreditation agencies Consumer groups and Consumer groups and US judiciary US judiciary

Supervision is both Procedural and Cognitive

Monitor v. Measure Monitor: is this happening ? Measure: How well is this happening?

How do we measure supervision? Qualitative Components Qualitative Components Quantitative Components Quantitative Components Qualitative / Quantitative Measurement Qualitative / Quantitative Measurement Resident Surveys/Program Evaluations 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 Time with resident : Time with resident : Direct contact with patient by attending Direct contact with patient by attending Direct contact with resident contributing to decision making and care plan Direct contact with resident contributing to decision making and care plan Direct contact with resident giving feedback 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 ) 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? Early in training Early in training Residents generally overestimate the level at which they can perform (some exceptions) Residents generally overestimate the level at which they can perform (some exceptions) Attendings generally underestimate the level at which residents can perform Attendings generally underestimate the level at which residents can perform Both reach equilibrium late in training Both reach equilibrium late in training The higher acuity of the patient makes even late in training residents ask for supervision 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 Trainee Considerations : Trainee Considerations : Trainees working proficiency Trainees working proficiency Quality of the treatment plan presented Quality of the treatment plan presented Trainee’s learning curve (as understood by supervisor) Trainee’s learning curve (as understood by supervisor) Level of training Level of training Trainee's self confidence Trainee's self confidence Trainee’s awareness of limitations Trainee’s awareness of limitations Lack of acquaintance of supervisor with trainee Lack of acquaintance of supervisor with trainee

Supervisor Considerations Supervisors’ general experience Supervisors’ general experience more experienced supervisors allow more autonomy more experienced supervisors allow more autonomy Balance of perceived supervisory role between patient responsibility (Care Provider) and resident education (Clinical Educator) Balance of perceived supervisory role between patient responsibility (Care Provider) and resident education (Clinical Educator)

Legal Standards Residents are held, in general, to the same standard of conduct as a practicing professional 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” 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” includes authorization of treatment plan, presence/availability at time of procedure includes authorization of treatment plan, presence/availability at time of procedure

Circumstantial Considerations Quality of the team to assist the trainee Quality of the team to assist the trainee Type of activity (high risk vs. low risk) Type of activity (high risk vs. low risk) Acuity of the patient Acuity of the patient Time of day Time of day

Next Steps Individual RRC’s are now formulating guidelines Need for new program specific supervision policies PGY Level Specific Knowledge, skills, attitudes (competency based) Explicit supervisory role of the attending

Example UTHSC Graduate Medical Education: Resident Supervision Policy UTHSC Graduate Medical Education: Resident Supervision Policy