Residency training has always had — and always will have — a dual mission: ensuring the safety of patients treated today by doctors-in-training, and ensuring the safety of patients treated in the future by current trainees once they have entered independent practice.
Surprisingly, these two goals conflict with each other. That is because proper graduate medical education, as I have explained in an earlier essay, requires doctors-in-training to assume responsibility for the management of patients. It is not enough for residents to watch senior physicians evaluate patients, make decisions about diagnosis and therapy, and perform procedures. Rather, trainees must learn to exercise these responsibilities themselves during their residency, lest their first patients in practice become victims of inexperience and inadequate preparation.
For this reason, the needs of today’s patients and those of tomorrow’s are not necessarily the same. Future patients depend on having well prepared doctors who gained extensive independent experience as residents. Their needs are served when inexperienced trainees manage complicated patients or perform major operations today, so once in practice doctors will be able to serve patients maximally. However, today’s patients benefit when they are cared for by the most experienced physicians available. Thus, residency training must consider the safety of both present and future patients. The challenge of achieving this balance has become particularly great during the last generation, as hospitalized patients have become much sicker, hospital stays much shorter, and medical practice ever more powerful and complicated. Mistakes of omission and commission now carry potentially greater consequences.
The key to maximizing the safety of both present and future patients is by providing house officers effective supervision in their work. Many studies have found that closer supervision of residents leads to fewer errors and improved quality of care. One review observed that increased deaths were associated with poor supervision of residents in surgery, anesthesia, emergency medicine, obstetrics, and pediatrics. Another study showed that the impact of better supervision on patient safety was particularly marked with less experienced residents. Despite the contemporary furor surrounding the issue of residents’ work hours, proper supervision has consistently been found to be much more important to ensuring patient safety than house officer fatigue.
We have much to learn about supervisory practices in medical education. However, current evidence suggests that the supervisory relationship is the single most important factor in the effectiveness of supervision. Especially important in this relationship are continuity over time, the supervisor’s skill at discharging oversight responsibilities while preserving sufficient intellectual autonomy for trainees, and the opportunity for both trainees and supervisors to reflect on their work. Other qualities of effective supervision have also been identified. Supervisors need to be clinically competent and knowledgeable and have good teaching and interpersonal skills. The supervising relationship must be flexible so that it changes as trainees gain experience and competence. Residents need clear feedback about their errors; corrections must be conveyed unambiguously so that residents are aware of mistakes and any weaknesses they may have. Helpful supervisory behaviors include giving direct guidance on clinical work, linking theory and practice, joint problem solving, and offering feedback reassurance, and role modeling. Ineffective supervisory behaviors include rigidity, intolerance, lack of empathy, failure to offer support, failure to follow trainees’ concerns, lack of concern with teaching, and overemphasis on the evaluative aspects of supervision.
Good supervisors, like good teachers, are made, not born. One advantage of proper supervision is the role modeling it offers residents for the supervision that they themselves may later provide. In addition, there is evidence that faculty can taught and motivated to be better teachers and supervisors.
It should be noted that good clinical supervision, like good teaching, is time-consuming. Many faculty members today find it difficult to provide the time necessary for close supervision and effective teaching because of the pressures they are under to increase their clinical or research “productivity.” For better supervision to flourish, medical schools will have to be willing to place a higher priority on the educational mission than in the past. This will entail a greater institutional willingness to promote clinical-educators, as well as the adaptation of “academies of medical educators,” mission-based budgeting, and other strategies to raise or identify funds to pay for clinical teaching and supervision. If patient safety is the goal, this is an effort worth undertaking.
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