Academic Medicine | December 2018 Watching residents Academic hospitalists deal with the challenge of balancing supervision and autonomy.

Any time the topic of attending supervision arises, the case of Libby Zion is sure to follow.

In 1984, the intern and resident who cared for the 18-year-old patient were under little supervision at New York Hospital, and their clinical decisions could have contributed to her death. The case led New York State to limit resident work hours and mandate the presence of senior physicians in the hospital in 1989. The Accreditation Council for Graduate Medical Education (ACGME) set similar nationwide standards in 2003 and further refined and updated them in 2011.

But while there's agreement that residents need structured supervision, the ideal amount can still be an open question, in part because the growth of hospital medicine over the same time period has brought forth its own set of supervisory changes. “Hospitalists have changed the game. They are now largely the attending of record for most inpatient services with housestaff,” said Kathleen M. Finn, MD, FACP, senior associate program director for the internal medicine residency at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School in Boston.

Before hospitalists, attendings would also have outpatient responsibilities and sometimes administrative duties, so they would spend maybe half of their time on the wards, said Joan B. Ritter, MD, FACP, deputy chief of the general internal medicine service at Walter Reed National Military Medical Center in Bethesda, Md. “The rest of the time, the residents could be flying solo, with phone calls periodically,” she said.

The omnipresence of academic hospitalists has changed patients' perceptions of care, according to a study of 22,400 patients hospitalized from 2001 to 2013. After each version of the ACGME duty-hour requirements was implemented, patients were increasingly more likely to report the attending physician, versus the intern or resident, as most involved in their care, according to results published in September 2015 by the Journal of General Internal Medicine.

With housestaff working fewer hours, attendings became the most continuous physician presence, said Jeanne M. Farnan, MD, MHPE, FACP, associate professor in the section of hospital medicine at the University of Chicago Pritzker School of Medicine. The attending, she said, became the continuity.

“We've seen this reflexive oversupervision, or what we call micromanagement, because the attending is the one who's always there providing the continuity, and there's been a lot of fragmentation of the way that housestaff coverage has happened,” said Dr. Farnan.

And so, the supervision pendulum could be said to have swung from laissez-faire to micromanagement. But with thoughtfulness and trust, attendings can provide sufficient oversight without being overbearing, experts said.

Too much of a good thing?

In its Common Program Requirements, ACGME defines different levels of supervision. Direct supervision involves the attending being physically present with the resident and patient, whereas indirect supervision occurs when the attending is physically present in the facility and immediately available to provide direct supervision, or is not physically present but is able to be reached immediately by phone or other electronic methods. A third category, oversight, is defined as when the attending is available to provide review and feedback of procedures and encounters after care is delivered.

While training as a resident in the early 1990s, Dr. Ritter said she was “probably undersupervised.” Three times a week, she rounded with her attending for an hour and a half, and she rounded with her team the rest of the time.

“But now, some of our attendings round for three hours every day with their team, and that is pretty much the expectation. Some residents never round without an attending,” said Dr. Ritter, also a clinical professor of medicine at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md.

At Dr. Finn's program in Boston, researchers put 22 faculty members to the test, assessing the impact of more direct attending supervision on the rate of medical errors and on resident participation during rounds.

The majority of Mass General's teaching attendings round on new patients but do not typically round with the team during work rounds, so this practice served as the standard supervision arm, said study coauthor Christiana Iyasere, MD, MBA, director of the hospital's Department of Medicine Innovation Program and Inpatient Clinician Educator Service. In the intervention arm, attendings joined work rounds on previously admitted patients in addition to bedside presentations of newly admitted patients.

More attending supervision during rounds did not significantly reduce the rate of medical errors, according to results published in July 2018 by JAMA Internal Medicine. At the same time, interns who received more supervision spoke significantly less, and fewer of them reported feeling efficient and autonomous, compared to those whose attendings did not join work rounds, the study found.

The results have garnered bemused feedback from attendings, said Dr. Iyasere, also an assistant professor at Harvard Medical School. “It truly makes people uncomfortable because I think people truly want to believe that having an attending around more and more will improve patient safety,” she said.

However, patient safety is a longer-term issue than the duration of a study, Dr. Finn pointed out. “If we put attendings on rounds now, all the time, and residents don't have the ability to learn and become independent practitioners, then long-term patient safety would be compromised,” she said.

While Dr. Farnan's own research has found favorable patient- and education-related outcomes of enhanced clinical supervision, she was not surprised to see the results given the many variables involved. “Supervision is not on one end of the see-saw and autonomy is on the other end,” she said. “So it really has to do with finding that right balance of supervision. It's not one-size-fits-all.”

The study findings raise an important question for hospitalists, who are constantly available in the hospital, Dr. Finn said. “Should you be in front of those residents all the time, or should you be giving them space to figure things out on their own?”

A delicate balance

When trainees receive too much supervision and not enough autonomy, they become apathetic, said Dr. Farnan. “There's not ownership in the patient because someone's just going to tell them the answer,” she said.

Dr. Finn agreed. “I think one of the things about the hospitalist movement in the last 20 years is that more and more residents now literally say, ‘What do you want me to do?’” she said. “I think that is a trend in the wrong direction.”

The ACGME states that the program director and faculty members are responsible for assigning the privilege of progressive authority and responsibility, conditional independence, and supervisory roles in patient care to each individual resident. Competency-based milestone assessments are designed to guide these evaluations.

For Dr. Finn, the milestones haven't been too helpful. “I understand the competency- and milestone-based training and I understand where people want to go with it, but I think the faculty here are literally rating our interns as ready for unsupervised practice [solely] because of the way those milestones are written,” she said. For example, a trainee may do a phenomenal job on one patient case but struggle on the next admission night, so “It's hard to label them with a milestone for that reason,” said Dr. Finn.

At the same time, however, the milestones provide an opportunity for residents to be more reflective about their progress and to be more explicit with faculty about expectations, said ACP Member J. Paul Happel, MD, chief of residents at Walter Reed and assistant professor of medicine at USUHS. “I think it works in both directions,” he said.

One way to help improve assessments is to also tailor supervision to an individual resident, which can be done simply by making it a priority, said Brian E. Neubauer, MD, FACP, chief of the general internal medicine service at Walter Reed and associate professor of medicine at USUHS. “These are not lengthy conversations, usually. Ask your residents what they are looking to get out of this rotation because a lot of times, they will tell you, ‘I've been working on this skill, and I'd like you to really pay attention to that,’” he said. (See sidebar for more tips on setting expectations at the start of a teaching service.)

When there is too much supervision, leadership skills can become stymied, said Dr. Happel. “If the attending doesn't give you the opportunity to manage the resources of your team, we're doing our trainees a disservice . . . because in a lot of circumstances, leading a medical team on the wards is their first opportunity as an adult to be a leader,” he said.

Of course, in the beginning, attendings are simply hopeful that residents can speak with patients appropriately, gather a good history, perform proper physical assessments, and begin to reason clinically, added Dr. Neubauer. But when evaluating higher-level functions like leadership, oversupervision encroaches on the progress of senior residents in particular, he said.

“If the attending is constantly present on rounds on a daily basis, there is going to be a tendency for all learners on the team . . . to go right to the attending for decision making,” said Dr. Neubauer. “And their presence on a daily basis voids, in some cases, the ability for that senior trainee to be the person to think through and make those decisions.”

Supervision behind the scenes

Attendings who want to provide a better balance of supervision and resident autonomy can look back to 2007, when a paper published in the Journal of General Internal Medicine coined the phrase “backstage oversight” to describe supervision of which the trainee is not directly aware. “I think that's the No. 1 thing that you can do,” said Dr. Farnan.

For example, electronic health records (EHRs) may be useful to assess how much supervision a trainee needs. “I think a lot of people lament the EHR, but I think it's provided us with a lot of really interesting opportunities to be able to see what's happening at the front lines of care when we're not there,” said Dr. Farnan.

During her own pre-EHR residency, her attending would come to rounds without knowing the labs, the vitals, or who the patients were beyond a sentence or two describing their medical problems. “Now, when I get up in the morning and I'm on the way to the hospital for rounds, I have all that information already,” Dr. Farnan said. “I think that it changes the dynamic of the way rounds run . . . and allows you to be more of a help when the residents reach out to you.”

For Dr. Finn, who uses the term “parallel rounding,” watching from a completely different floor as residents put in orders and then prompting them through a text or page is the best part of having an EHR.

However, indirectly supervising through the EHR may actually take more time than joining rounds, Dr. Happel noted. Most attendings would not only look at the EHR but would also go see the patients on their own before meeting with the team later to compare observations and review the plan, he said.

“I can do all of that in rounds all at once, or I can do it in three stages, which I think takes more time, and time is everything,” said Dr. Happel. “So a lot of attendings are like, ‘Yeah, it'd be great if I could give them more autonomy, but it's just easier and more efficient for me to be on rounds every day.’”

This line of thinking, Dr. Ritter added, is “attending-centered, not learner-centered.” While junior learners don't have to be completely autonomous, the appearance of autonomy is crucial, she said. “When I was a medical student, I went into internal medicine because I thought my resident knew so much and he was so independent,” said Dr. Ritter. “I don't know if the learners see their residents that way anymore.”

Disclaimer: The views expressed in this article belong to the sources alone and do not necessarily reflect the official position of the United States Department of Defense, the United States Department of the Navy, or Walter Reed National Military Medical Center.