We can all learn from our own mistakes – in health care, the question becomes at what cost? The world has dramatically changed since the mid-1980s, when the case of Libby Zion hit the news, and gaining clinical experience could be summed up as “See one – Do one – Teach one.”

At that time, there was little resident supervision, particularly on holidays and weekends. It was also considered a badge of honor not to call on senior residents or attending physicians at night for help.

Although much has changed for the better, we continue to struggle with defining the most appropriate balance between autonomy and supervision.

Four major events have led to significant improvements in resident supervision.

First, changes to the Medicare Rule for Teaching Physicians in 1996 dictated that attending physicians must be present during the key components of any service or procedure. Second, as reported by Fromme et al., “In 2000, the Accreditation Council for Graduate Medical Education introduced a new … competency-based approach to residency education, assessment of performance became a main area of interest, and direct observation was offered as a tool to assess knowledge and skills.”

Third, the Institute of Medicine’s (IOM’s) 2008 report titled, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” made recommendations for limiting resident hours and increasing resident supervision.

Finally, in 2010, the Accreditation Council for Graduate Medical Education (ACGME) adopted common standards that provided detailed training program recommendations, particularly in regard to first-year trainees.

The new standards require that each training program include:

1. Direct supervision, which requires the physical presence of the supervising faculty member;
2. Indirect supervision, in which the supervising faculty member or a more advanced resident is immediately available in the facility to provide direct supervision, is available by phone or other electronic modality to provide direct supervision; and
3. Oversight, in which post hoc review of resident-delivered care is conducted and feedback is given to the resident regarding the appropriateness of that care.

The Council of Residency Directors has made similar recommendations recently regarding the establishment of clinical expectations for performance based on year of training.

Although changes in reimbursement and regulation play a role, they are not the only factors that have driven these improvements. Several important studies have shown increased risk to patients and liability tied to inadequate supervision. A 2004 article published in the Journal of the American Medical Association estimated that residents were named in 22 percent of malpractice claims.

However, less than 1% of all claims resulting in a payment actually had a named resident as a defendant, as it is common for residents to be dropped as named defendants, which means they are not reported to the National Practitioner Data Bank when covered by a medical school or hospital.

Therefore, payments made on behalf of a resident are generally as a result of resident participation in patient care and are likely to be greater. Further, recent emergency medicine data from the Physician Insurers Association of America (PIAA) showed that the percentage of paid claims rose from 22.6% to 33.8% when a resident was involved, and the average indemnity paid went from $223,373 to $280,347.

Additionally, observations from a study that appeared in the Journal of General Internal Medicine in 2010 showed that errors are more common in early summer, when new residents and interns begin their training – the so-called “July effect.”

In this study, the authors found that the number of hospital patients who died from medication errors spiked 10% in July, but only in counties with teaching hospitals.

In an Archives of Internal Medicine article titled “Medical Errors Involving Trainees,” the authors reviewed 240 malpractice claims and found that the types of medical errors affecting trainees included:

• Judgment error (72% of cases)
• Memory or vigilance error (57% of cases)
• Lack of technical competence or knowledge (58% of cases)
• Lack of supervision (54% of cases)
• Handoff problems (19% of cases)
• Excessive workload (19% of cases).

Common high-risk misses included failure to:

• Correctly time onset of acute stroke
• Recognize serious injury in geriatric trauma patients
• Recognize the presentation of aortic dissection
• Recognize surgical pathology in elderly patient who have abdominal pain
• Appreciate the significance of a patient who presents multiple times with the same complaint
• Initiate timely consultation or transfer for critically ill patients.

Important to note in these malpractice cases is that a resident is generally held to the same standard as other residents with similar training, a general practitioner, or an attending specialist, depending on the locale and circumstances of the case.

It is highly likely, however, that the supervising physician will be held liable if a bill is submitted for which the supervising physician claims to have overseen the resident and agrees with the documentation and plan.

Discussing the balance between supervision and autonomy is important. Direct supervision comes at a cost because it (1) requires increased manpower, (2) impacts patient flow, (3) takes attending physicians away from direct care, and (4) affects residents’ decision-making.

These factors must be weighed against the level of oversight necessary to ensure patient safety. Many institutions have adopted a graded level of supervision based on the experience of the resident, observed clinical competency, and the complexity of the case.

No clear answer is suited for all circumstances. However, below are some common strategies that attempt to strike the right balance.

• Younger physicians generally require more supervision earlier in their careers.
• More complex patients or procedures may require a greater level of direct supervision.
• Asking for help early in a case is often better than delaying a request for help.
• Increased communication should be encouraged, and supervising faculty should set expectations that address any resident concerns or fears about appearing unintelligent or weak or complaining of fatigue.
• Residents should adopt a team approach on three fronts: (1) all residents should feel empowered to speak up; (2) all residents should be included in discussions; and (3) reporting errors, adverse events, and near misses should be encouraged.
• Consider adopting “triggers” that mandate communication with attending physicians, such as a change in clinical status, patient transfer to another facility, and sentinel events, such as cardiac arrest or transfer to the intensive care unit.
• Using regularly scheduled times to contact faculty can enhance communication.
• Programs should comply with current hospital bylaws and ACGME requirements.
• Residents should be involved in both claims and patient safety programs.
• Inform residents of pertinent hospital policies and guidelines, such as HIPAA regulations, clinical guidelines, moonlighting malpractice coverage, and transfer protocols.
• Consider developing tiered responses that are based on the complexity of the patient and/or procedure.
• Structured handoff processes, such as emergency department rounding with the team, can decrease communication errors.

Much can still be done to mitigate risk by ensuring appropriate and adequate supervision for physicians in training. The fundamentals of a good risk strategy are based on open communication, handoffs, scope of practice, transparency, and documentation.

Dr. Billingham is an emergency physician and Chief Medical Officer for Medical Protective Insurance Company and is Emeritus Chair of the Emergency Medicine Patient Safety Foundation. Dr. Gelb is a professor of emergency medicine at the University of California, San Francisco and is chair of the UCSF Risk Management Committee at San Francisco General Hospital.