Strategies for Safe and Effective Resident Supervision


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Presented at Accreditation Council of Graduate Medical Education (ACGME) meeting in Nashville, TN Mar 2010. Includes overview of resident supervision, function and type of supervision in various specialties, and the SUPERB/SAFETY model of effective supervision. Includes link to video on YouTube for facilitating discussion.

Published in: Health & Medicine, Education
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  • Good presentation!
    Work hours also attract attention and have dicussions on the issue in Taiwan. I quite agree with your point we should pay much more attention to 'appropriate supervision', which will be more effective to enhance interns/residents' learning and practice.
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  • YEvening of March 5, 1984, 18yo female was admitted at New York Hospital fever CXR clear, WBC >18K(41 o C), dehydration, and “uncontrollable shaking” Admitted with viral syndrome with “routine vital signs” ou may never have heard of the Libby Zion case, but it has probably influenced your career as a house officer more than any other litigation. Libby Zion was an 18-year-old woman admitted to Cornell Medical Center's famed New York Hospital the evening of March 4, 1984. She was brought there by her parents, manifestly ill, with high fever (41C), signs of dehydration and "uncontrollable shaking." She had a clear chest x-ray and a WBC of 18,200/cu. mm. Libby was admitted to a four-patient room, with a tentative diagnosis of "viral syndrome." The admitting orders specified "routine vital signs." The Zions left their daughter's bedside in the early hours of March 5, 1984, assured by the house officers that she would be OK. A few hours later, at 7:45 a.m. March 5, the parents received a call that Libby Zion was dead. From the beginning, medical negligence was assumed by the family. Sued were three hospital residents, the attending physician, and New York Hospital. Investigation revealed that, prior to admission, she had been taking Nardil (phenelzine), an antidepressant prescribed by her psychiatrist, and that one of the house officers gave 25 mg. Demerol to control her shaking spells. The drugs are not supposed to be used together. The intern in charge was off on another ward between 3:30 a.m. and 6:30 a.m., when Libby Zion went into cardiac arrest, and during that period she never checked on her patient. Also, the nurses reported calling this house officer two or three times because of the patient's agitation, and the intern had ordered "a posey jacket." At the trial there was conflicting evidence about cocaine being present in Libby Zion's blood (one test showed it was, one test showed it wasn't). The medical examiner officially ruled her death as due to "bilateral bronchopneumonia" and that she died of a very high fever and "sudden collapse" soon after receiving injections of Demerol and Haldol "while in restraints for toxic agitation." Libby had not been started on any antibiotics while in the hospital.
  • Most definitions of supervision, with respect to clinical medicine, emphasize promoting professional development AKA clinical expertise and ensuring patient safety. There is a wide variation in the amount and frequency, although there is evidence that supervision has a positive impact on patient outcomes (ED paper, PICU paper) Three key features that have been highlighted in the definition of supervision is that it should be: Normative or have an administrative/management component Formative or an educational component Restorative or a supportive component Differing levels of supervision have been defined within specific specialties, such that there is a differentiation between direct supervision “I was present for the key portion of the procedure” which requires the physical presence of the attending during the key aspect of patient care Participatory-when faculty provide oversight prior to or during the care of the patient Indirect-what we are all probably most familiar with, faculty review the care given to patients by examination of medical record/discussion of treatment plan with resident These designations were defined in the Virginia Consensus on Resident Supervision
  • Issues of supervision during residency training are important because of their implications in 3 domains, namely patient safety, financial and legal Patient safety  Among medical educators there is the general agreement that the main aims of supervision are to promote professional development (the training of competent physicians) and to ensure patient safety. I’m sure many of you are familiar with the 1984 Libby Zion case in which an 18y/o woman died in a NY hospital, contributing causes of which were determined to be “resident exhaustion and inadequate supervision”. As a result of this media attention became focused on physician work hour regulation ‘the duty hours’ but little focus has been on supervision Financially , re-imbursement for clinical service has been dictated by the HCFA guidelines (now CMMS) which states that an attending physician must be physically present in order to bill for services provided by a resident or fellow; this change in billing guidelines in 1996 was born out of the phenomena of the absent attending, and patients billed for services under ‘attendings of record’ who were otherwise absent. Although a result of fraudulent billing, this requirement for attending presence has impacted training, but the question does remain if physical presence=supervision? Issues of risk management dovetail nicely with the next domain…
  • As I stated previously, HCFA guidelines were instituted to ensure appropriate billing practices however have impacted residency training…JGIM article discusses that although HCFA resulted in dramatic increase in overall time spent with attending, less time dedicated to education/clinical teaching Despite the publicity of the Libby Zion case and NY 405.4, the discussion of residency supervision in the duty hours language is vague “All patient care must be supervised by qualified faculty…rapid/reliable system for communicating with faculty….faculty schedules must be structured to provide residents with continuous supervision and consultation” In addition the RRC guidelines for Internal Medicine illustrate the struggle between resident autonomy and supervision, with general guidelines such as “faculty must be available in a timely fashion for resident consultation” but not structured recommendations State dependent legislation such as NY 405.4 have explicit language re: “24hr on site ED MD, 24hr anethesia, medicine ob/gyn, peds surgery attendings (high rates of non-compliance) Legal loophole-if not on site must be able to be at hospital in 30min…If an attending is available by phone, on-site supervision can be provided by sr residents” . Despite push for compliance with the duty hours, supervision compliance has been lacking and clearly isn’t monitored as stringently as duty hours Seemingly 24hr attending availability extends to IL law, medical students unable to participate in patient care without the physical presence of the attending Eg Virginia, Harvard Hospitals
  • We detected no association between implementation of telemedicine technology and adjusted hospital or ICU mortality, LOS, or complications. Our results differ from those from a previous report 6 and should be interpreted in light of 3 factors that may influence the effectiveness of a tele-ICU: (1) how the tele-ICU was used by the remote intensivists to alter care in the monitored units; (2) its acceptance by physicians in the monitored units; and (3) integration of the information systems of the tele-ICU and the monitored units. Interestingly, our regression models suggested a decreased risk for more severely ill patients (SAPS II scores 39) after tele-ICU implementation. Thus, proponents of tele-ICU systems might suggest that the mortality reduction we observed among the sickest patients was because the sickest patients were those most likely to have unexpected changes in their medical condition (eg, arrhythmia, hypotension, sepsis, hypoxia) that required rapid intervention. The tele-ICU can provide this rapid response because of the constant monitoring (including computer-issued alerts sent to the remote intensivist to report changes in key physiological parameters) and availability of nurse and physician intensivists. The 60-day surveillance data suggested that tele-ICU physicians frequently provided such timely and critical interventions, especially in the open ICUs. Clinician acceptance of the technology is also important. The fact that almost two-thirds of the patients in our study had physicians who chose minimal delegation to the tele-ICU may have contributed to our inability to find no mortality benefit, even though the tele-ICU physicians could still intervene in life-threatening situations. Had more physicians delegated full responsibility to the tele-ICU, less ill patients might have benefited from the routine care provided by the tele-ICU. The lack of an overall mortality reduction may also be explained by the degree of integration of the tele-ICU and remote units. Physicians and nurses in this tele-ICU had access to real-time vital signs and wave tracings, laboratory values, imaging studies, and the medication administration record. However, the tele-ICU and the monitored units did not share clinical notes or computerized physician order entry within a common electronic record. These notes were instead faxed to the tele-ICU daily. Greater integration of clinical information might have resulted in a larger effect on mortality. Our study has other strengths and weaknesses. We surveyed the ICUs regularly and found no quality improvement projects focused on the sickest patients (such efforts could explain the lower mortality in those patients). Our sample of patients and ICUs was larger and more heterogeneous than those in previous reports, 6 and our data were collected by an explicit and reliable medical record review (in contrast to administrative data). Implementation of the tele-ICU occurred sequentially throughout the system over an 18-month period, and we waited several weeks before starting postintervention data collection. This allowed for managers of the tele-ICU and each unit to work out startup problems associated with implementation of such a complex technology and mediated any seasonal changes in mortality. We have no data on survival following hospital discharge. It is possible that the tele-ICU intervention led to the sickest patients being transferred more quickly to hospice or other sites of care, where they died. Such transfers may have been an appropriate improvement in care, but without data on survival following hospital discharge we do not know if the 20% to 50% reduction in hospital mortality among the sickest patients translates to the same reduction in long-term mortality. Although the nurse data collectors were not told if a medical record was from the preintervention or postintervention period, something written by a caregiver could have indicated that the record was from the tele-ICU period. The lack of association between the tele-ICU intervention and complications was not anticipated but can be explained by the above-noted lack of acceptance and integration of the tele-ICU. Another possible explanation is detection and surveillance bias. The presence of the tele-ICU may have led to increased surveillance for, and documentation of, complications by the physicians and nurses in the monitored units.
  • Non-significant increase (on 4 point Likert-type scale) in residents’ perception of pressure (mean pre 3.0 vs. post 2.0), isolation (mean pre 3.0 vs. post 1.0), learning (mean pre 2.0 vs. post 2.0) or satisfaction with experience (mean pre 1.0 vs. 1.0). Qualitative comments noted “[the presence of the attending] is more often symbolically satisfying, than a real help”
  • Mention with each end of spectrum to un-clutter slide… Lack of faith in clinical competence Resident apathy Sense of abandonment Uncertainty in clinical decision making
  • John paro, Vivian chang, Keiki hinami
  • Strategies for Safe and Effective Resident Supervision

    1. 1. Strategies to Improve Trainee Supervision (SES87) Jeanne M. Farnan, MD MHPE Vineet M. Arora, MD MAPP The University of Chicago Department of Medicine & Pritzker School of Medicine
    2. 2. Disclosures <ul><li>Grants and Contracts </li></ul><ul><ul><li>ACGME </li></ul></ul><ul><ul><li>ABIM Foundation </li></ul></ul><ul><ul><li>ACP Foundation </li></ul></ul><ul><ul><li>AHRQ </li></ul></ul><ul><ul><li>NIA </li></ul></ul>
    3. 3. Who is in the room? <ul><li>Surgery (inc surgical subspecialty ortho, OHNS, plastics, NUS, urology, etc.) </li></ul><ul><li>Emergency Medicine, Anesthesia, or OB/Gyne </li></ul><ul><li>Neurology, Pediatrics, Pyschiatry, Medicine or related subspecialty </li></ul><ul><li>Radiology/Rad onc, Dermatology, Optho, Pathology </li></ul><ul><li>Other? </li></ul>
    4. 4. Outline <ul><li>History, Policy & Types of Supervision </li></ul><ul><li>What do we know about supervision? </li></ul><ul><ul><li>Review of literature to identify best practices & gaps across specialties </li></ul></ul><ul><li>Understanding & improving nighttime supervision </li></ul><ul><ul><li>Uncertainty & medical decision making </li></ul></ul><ul><li>Introducing the SUPERB/SAFETY model </li></ul>
    5. 5. Increasing Focus on Supervision <ul><li>Spent a lot of time discussing and regulating duty hours since 1980’s </li></ul><ul><li>Little attention has been paid to appropriate supervision </li></ul><ul><ul><li>Despite calls to improve </li></ul></ul>
    6. 6. The Case of Libby Zion, March 4, 1984 11:00pm 1:00am 3:00am 5:00am 7:00am 18 yo F presents with fever (41 o C), dehydration, and “uncontrollable shaking” Labs/studies: WBC >18K CXR clear Because of increasing agitation and uncontrolled shaking, nurses call intern several times Intern phones order for Posey jacket Libby Zion goes into cardiac arrest Haldol and cooling blanket for cont. fever Admitted to ward, given Tylenol Seen by intern and resident. Dx: “viral syndrome with hysterical symptoms” Demerol given Asch, Parker, &quot;The Libby Zion Case. One Step Forward or Two Steps Backward?&quot; 1988.
    7. 7. Did Supervision Get Lost? <ul><li>Bell Commission </li></ul><ul><ul><li>A major recommendation of the Bell Commission was to improve supervision </li></ul></ul><ul><li>Ultimately, this report led to the restriction of duty hours </li></ul><ul><li>“ Supervision is more important than [duty] hours…” </li></ul><ul><li>-Dr. Bertrand Bell, 2009 </li></ul>
    8. 8. Supervision & Autonomy Struggle <ul><li>Traditionally programs have been evaluated by ACGME on the ability to promote resident autonomy </li></ul><ul><ul><li>Graduated responsibility to prepare residents for independent practice </li></ul></ul><ul><li>Tension between supervision & autonomy </li></ul>
    9. 9. Aims of Supervision <ul><li>Amongst medical educators </li></ul><ul><ul><li>Promote professional development </li></ul></ul><ul><ul><li>Ensuring patient safety </li></ul></ul><ul><li>Desired features of supervision </li></ul><ul><ul><li>Normative = highlighting standard of care </li></ul></ul><ul><ul><li>Formative = feedback for improvement </li></ul></ul><ul><ul><li>Supportive = reflection & assistance </li></ul></ul><ul><li>Little guidance as to the nature/extent of supervision to be provided </li></ul>Med Educ 2000; 34:827-840,Med Educ 2005; 39: 696-703
    10. 10. Implications of Supervision <ul><li>Patient Safety </li></ul><ul><ul><li>Prevent adverse outcomes </li></ul></ul><ul><ul><li>Institutional liability </li></ul></ul><ul><li>Medical education </li></ul><ul><ul><li>Train competent physicians </li></ul></ul><ul><li>Re-imbursement </li></ul><ul><ul><li>HCFA/CMS guidelines </li></ul></ul>JAMA 2004; 292 (9): 1051-1056, Lownsbury v VanBuren
    11. 11. Types of Supervision Housestaff Supervision Policy, VA Consensus 2005 Type Definition Example Direct Direct contact with patient and participation in providing care alongside resident Cesarean delivery Participatory Oversight prior to or during patient care Guiding resident doing chest tube placement Indirect Review of care given by resident after the fact Post-call Internal Medicine rounds
    12. 12. Specialty-specific Policy: OB <ul><li>“ Adequate supervision requires 24-hr presence of faculty in the hospital except when residents are not assigned in-house call... Faculty must be immediately available clinical activity is taking place in the OR and/or L&D areas. Faculty must be within easy walking distance… Clinical services provided in ambulatory locations require on-site supervision .” </li></ul> Program Requirements Ob/Gyn
    13. 13. Specialty-specific Policy: Surgery <ul><li>“ The program director must provide a summative evaluation for each resident upon completion of the program... verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.” </li></ul><ul><li>Current RRC guidelines in IM DO NOT detail what constitutes faculty supervision </li></ul><ul><ul><li>In contrast to other detailed RRC’s </li></ul></ul> Program Requirements Gen Surgery
    14. 14. Challenges: Defining Effective Supervision <ul><li>“ If you were to ask a dozen IM faculty what constitutes adequate resident supervision, you would probably get as many different answers…” </li></ul>Casner, 1995.
    15. 15. Other policies <ul><li>State-dependent legislation </li></ul><ul><ul><li>Illinois State Law </li></ul></ul><ul><ul><li>(225 ILCS 60/) Medical Practice Act of 1987 </li></ul></ul><ul><ul><li>“ Medical students…may practice under the direct, on‑premises supervision of a physician who is licensed in Illinois AND who is a member of the faculty of an accredited medical or osteopathic college” </li></ul></ul><ul><li>Academic center-dependent guidelines </li></ul>
    16. 16. Recent Technological Advances in Supervision <ul><li>Telemedicine and the eICU </li></ul><ul><li>Online tools </li></ul><ul><li>Video conferencing </li></ul>
    17. 17. Recent Recommendations <ul><li>12/08 IOM Report on duty hours </li></ul><ul><ul><li>Recommends augmenting resident supervision </li></ul></ul><ul><li>24/7 on-site attending supervision for ALL GME programs </li></ul><ul><li>Impact of attending supervision on resident education & patient outcomes? </li></ul>
    18. 18. What do we know about supervision? Review of literature to identify best practices & gaps
    19. 19. Existing Evidence <ul><li>Systematic review of the current literature to </li></ul><ul><ul><li>Describe effect of clinical supervision interventions on residency education & patient outcomes </li></ul></ul><ul><ul><li>Multi-specialty focus </li></ul></ul><ul><ul><li>Where are the gaps? </li></ul></ul>
    20. 20. Standardized Data Abstraction <ul><li>Design, type of supervision </li></ul><ul><li>Clinical setting, supervisor & trainee role, specialty, outcomes </li></ul><ul><li>Performed by three authors </li></ul>
    21. 21. Study Quality: MERSQI <ul><li>Medical Education Research Study Quality Index </li></ul><ul><li>Developed and validated by Reed et al. </li></ul>Reed et al. JAMA 2007, Reed et al. JGIM 2008.
    22. 22. Supervision Studies (n=14) Specialty # of studies Clinical context Average MERSQI’s (1-18) Night-time supervision assessed Psychiatry 4 Psychotherapy & night consults 13 Yes Internal Medicine 3 Outpatient clinic, Attending rounds 11.5 No Emergency medicine 3 Enhanced attending presence in ER 12.3 No Surgery 3 Enhanced attending presence in OR 9.16 No Anesthesia 1 Intubation 12.5 No
    23. 23. Supervision Study Summary <ul><li>All but 1 study suggest that enhanced attending supervision in already supervised activities (clinic, surgery, etc.) improves outcomes </li></ul><ul><li>Interestingly, more studies actually (11) examined patient outcomes </li></ul><ul><ul><li>only 5 examined educational outcomes </li></ul></ul>
    24. 24. Nighttime Supervision Source Design & Participants Supervision Intervention Educational Outcomes Patient Care Outcomes MERSQI Finlayson AJ et al, 1977 Pre-post study of 24 ER-psychiatric residents at AMC On-site direct attending supervision overnight of night consult residents Non-significant decrease in residents’ perception of extra pressure, isolation Increased perception of sharing the responsibility No change in learning or satisfaction 9.5
    25. 25. Night-time Supervision <ul><li>Qualitative comments: </li></ul><ul><li>“ [the presence of the attending] is more often symbolically satisfying, than a real help” </li></ul>
    26. 26. So What Do We Know? <ul><li>Enhanced attending supervision during routinely supervised activities may improve patient outcomes & resident education </li></ul><ul><li>Only 1 study to date examining effects of enhanced night-time attending supervision </li></ul><ul><ul><li>Unclear impact on meaningful outcomes </li></ul></ul>
    27. 27. Understanding and improving nighttime supervision Supervision theater
    28. 28.
    29. 29. Debriefing <ul><li>What types of barriers or facilitators did you observe? </li></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Cultural </li></ul></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Any others? </li></ul></ul>
    30. 30. The University of Chicago Experience… The good, bad and ugly of nighttime supervision
    31. 31. Competing Factors Resident Attending Autonomy Hidden Curriculum Clinical expertise Billing pressures Research/clinical obligations Lack of formal supervision training Liability, Institutional culture Patient Care
    32. 32. Methods: Setting <ul><li>January through November 2006 </li></ul><ul><li>In-house call every 5 th night </li></ul><ul><li>10 new admissions per call night </li></ul><ul><li>Focus on attending-resident relationship </li></ul>Attending Physician General Internal Medicine/Subspecialty Senior resident PGY-2/3/4 Categorical or preliminary intern Categorical or preliminary intern
    33. 33. Survey <ul><li>General supervision practices: </li></ul><ul><ul><li>“ There were clinical scenarios for which I wished I would’ve been contacted earlier” </li></ul></ul><ul><li>Attending-level notification for: </li></ul><ul><ul><li>Diagnostics (performing LP) </li></ul></ul><ul><ul><li>Therapeutics (IV antibiotics) </li></ul></ul><ul><ul><li>Transfer of care (ICU transfer) </li></ul></ul><ul><ul><li>Sentinel/adverse events (cardiac arrest) </li></ul></ul>Farnan, et al. Amer J Med. 2009
    34. 34. Interviews <ul><li>Critical incident technique used to solicit examples of ineffective supervision </li></ul><ul><li>Appreciative inquiry used to solicit examples of effective supervision </li></ul><ul><ul><li>“ What would you consider to be effective supervision?” </li></ul></ul>Flanagan JC. Psychological Bulletin. 1954; 51.4:327-359 Appreciative Inquiry commons.
    35. 35. Attendings & Residents Differ on Perceptions of Supervision <ul><li>Response rate </li></ul><ul><ul><li>44/50 (84%) attendings & 46/50 (92%) residents (38% hospitalists) </li></ul></ul><ul><li>81% of attendings vs. 91% of residents reported contact [personal or telephone] at least once per call night </li></ul><ul><li>Perception of frequency that attending input changed patient plan of care: </li></ul><ul><ul><li>21% (attendings) vs. 10% (residents) p=0.001, [0.13,0.18] </li></ul></ul>
    36. 36. <ul><ul><li>Attendings wished to be contacted earlier regarding patient issues than residents desired to contact them (z=2.882, p=0.004) </li></ul></ul>Attending Resident # of respondents
    37. 37. Disparity in Supervision Preferences <ul><li>Attendings expressed a greater desire to be notified than residents wished to notify them for the following: </li></ul><ul><ul><li>Receiving transfer pt from ICU (p=0.0009) </li></ul></ul><ul><ul><li>Receiving transfer pt from outside facility (p=0.001) </li></ul></ul><ul><ul><li>Initiation of vaso-active medications (p=0.02) </li></ul></ul><ul><ul><li>Initiation of IV antibiotics (p=0.003) </li></ul></ul>
    38. 38. Similarities in Supervision Preferences <ul><li>Residents and attendings agreed that immediate notification was warranted for: </li></ul><ul><ul><li>ICU transfer of an existing patient </li></ul></ul><ul><ul><li>Cardiac/respiratory arrest </li></ul></ul><ul><ul><li>House-staff personally performing an invasive procedure </li></ul></ul>
    39. 39. Models of Supervision <ul><li>“ Micro-manager” </li></ul><ul><li>“ Absentee” </li></ul><ul><li>Characteristics of effective supervisors: </li></ul><ul><li>“ Safety net” </li></ul><ul><li>“ Teacher” </li></ul><ul><li>“ Mentor” </li></ul><ul><li>“ Role model” </li></ul>SUPERVISION “ We didn’t have a lot of autonomy with our attending, it kind of got dull and a lot of the housestaff withdrew from aspects of care because we just knew that weren’t going to make decisions anymore” “ I think that there was one time where I paged him and I think he was in a meeting so I didn’t even hear from him… And so I needed, I wanted an attending to attending conversation because I didn’t think that we should be taking care of [this patient] ” Resident apathy Lack of faith in clinical competence Abandonment Medical decision making uncertainty
    40. 40. Conclusions <ul><li>Attending desire to supervise is greater than resident desire to seek supervision </li></ul><ul><ul><li>Attending physicians wish to be contacted earlier and more often </li></ul></ul><ul><li>Two extreme models of attending clinical supervision observed </li></ul><ul><ul><li>Both with detrimental effects on residents </li></ul></ul><ul><ul><li>Attending-level education needed?? </li></ul></ul>
    41. 41. If residents are not contacting their attending at night, how are they making decisions? Medical decision-making during uncertainty
    42. 42. Aims <ul><li>Describe resident uncertainty during times of clinical decision-making </li></ul><ul><li>Identify resident response to uncertainty </li></ul><ul><ul><li>Specifically, when did residents seek (or not) attending input at night </li></ul></ul><ul><li>Describe impact of resident uncertainty on delivery of patient care </li></ul>
    43. 43. The Beresford Model of Clinical Uncertainty Type Definition Case example Conceptual Do not know how to apply abstract framework to make decision Don’t know when to transfer a patient to the ICU Technical Lack knowledge regarding specific content domain or task Don’t know how to do an LP or run a code Personal Not familiar with patient or patient wishes Don’t know baseline mental status or prior course after a patient is signed over to you
    44. 44. Uncertainty & Patient outcomes <ul><li>18 discrete critical incidents identified </li></ul><ul><ul><li>10 discrete adverse outcomes identified </li></ul></ul><ul><ul><ul><li>6 involving delay in indicated procedure or diagnostic testing </li></ul></ul></ul><ul><ul><ul><li>2 suffered procedural complications </li></ul></ul></ul><ul><ul><ul><li>2 suffered cardiac arrest/death </li></ul></ul></ul>
    45. 45. Domain (n) Major category (n) Sub-theme (n) Technical Uncertainty (5) Procedural skills (4) Knowledge of Indications (1) Conceptual Uncertainty (11) Transitions of care (6) Escalations of Care (5) Discharge Readiness (1) Diagnostic decision-making (4) Management conflict (1) Communicative Uncertainty (2) Goals of Care (2)
    46. 46. Technical Uncertainty *Of the 4 patients identified as cases where residents expressed procedural anxiety, none received the procedure in question Major categories Representative comments Representative Patient Outcome Procedural skill (n=4) CC: Patient with HIV/AIDS, fever, and mental status changes “… just the standard work up included an LP and I felt like I couldn ’ t get, I am not trained on how to do them and I just felt like lets do this tomorrow …” Pt. treated empirically with meningitis-appropriate doses of antibiotics. Did not receive LP*
    47. 47. Conceptual Uncertainty Major categories Representative comments Patient Outcome Transitions of care (n=6) Sub-theme: Escalation of care CC: Patient with sodium of 107 “ I was really uncomfortable and nervous about it and it was one of he few times that I was so uncomfortable taking care of a patient on the floor…I ended up reassured a few hours later when clinically she was fine but probably when I think about it, if one of my interns was as uncomfortable as I was with that patient I would expect them to tell me about it and yet by the time this happened it was 1 or 2AM and I think if it had been 8PM I would have called him [my attending]…I even told him I wasn’t sure if I could call about this” Patient did not require escalation of care; patient did not suffer adverse event
    48. 48. Personal Uncertainty Major categories Representative comments Patient Outcome Goals of care (n=2) CC: Patient with severe COPD transferred from Medical ICU to Gen Medicine service “ you know I discussed with a lot, with this particular patients outpatient attending and the decision was made pretty quickly to make him comfort care and he actually died that day and I never actually talked with my attending about that patient until I talked with her later in the night and said that he had passed away and then the next day it was obvious that we had missed something on the chest x-ray…” Patient made comfort care and expired after unrecognized complication
    49. 49. Resident Management of Uncertainty: Hierarchy of Assistance “ I do “Up-to-Date” first of all and then try to get a differential and then come up with some thing ” Attending Fellows Sr. Residents Peers/Co-residents Literature
    50. 50. Resident Management of Uncertainty: Hierarchy of Assistance “ Look it up if I can’t find anything reasonable to back up something, you know if I look it up and it’s a reasonable approach, talk to my colleagues, if they have had any experience with that “ Attending Fellows Sr. Residents Peers/Co-residents Literature
    51. 51. Resident Management of Uncertainty: Hierarchy of Assistance “ I would probably say MICU is the main person that I would ask on call, the MROC is the other person” Attending Fellows Sr. Residents Peers/Co-residents Literature
    52. 52. Resident Management of Uncertainty: Hierarchy of Assistance “ Sometimes I curbside the appropriate fellow, I think I do that quite a bit, I think I do that more than talking to the attending” Attending Fellows Sr. Residents Peers/Co-residents Literature
    53. 53. Resident Management of Uncertainty: Hierarchy of Assistance “ So if I have something that is really pressing I would probably page my attending because you know he’s my boss…” Attending Fellows Sr. Residents Peers/Co-residents Literature
    54. 54. Determinants of Seeking Attending Advice Barriers (7) Facilitators (6) Conflict with autonomy (2) Existence of hierarchy (2) Fund of knowledge expectations (2) Fear of repercussion (1) Need for escalation of care (4) Options in Decision-making (1) Clinical experience (1) Attending persmission (1) “ I thought my attending was very smart but it was a pain to kind of run by things with him when he was there because it would kind of influence things too much and then you wouldn’t get a chance to make up your own mind and figure it out.” “ it wasn’t anything that critical it needed to be addressed that night, if I had been I would have been totally comfortable calling my attending because she made it a point to know that that was fine in calling”
    55. 55. Implications <ul><li>Residents are not pursuing supervision at potential times of patient vulnerability </li></ul><ul><ul><li>Possible contributor to adverse events </li></ul></ul><ul><li>Numerous barriers – at both the attending and resident level – prevent residents from seeking supervision </li></ul><ul><ul><li>Hierarchy of assistance embedded in the hidden curriculum within residency training </li></ul></ul><ul><li>Residents need to be educated on the importance of attending-level supervision </li></ul>
    56. 56. Strategies to teach Supervision to Attending and Resident Physicians The SUPERB/SAFETY Model
    57. 57. Education at BOTH levels <ul><li>Formal training in effective supervision practices needed: </li></ul><ul><ul><li>Attending education regarding the balance between autonomy and supervision </li></ul></ul><ul><ul><li>Resident education regarding: </li></ul></ul><ul><ul><ul><li>Attending’s responsibility to supervise </li></ul></ul></ul><ul><ul><ul><li>Importance of recognition and management of uncertainty </li></ul></ul></ul>
    58. 58. Suggestions for Attendings Domain (n) Representative quote Set expectations for notification (41) “ if serious status change happens on a patient, meaning they go the unit, they die or if they clinically deteriorate, to let me know” [A] Uncertainty (68) “ I even told [my attending] I wasn’t sure if I could call, and he said definitely, call when you are unsure like this…” [R] Planned communication (36) “ on call she was to call me typically a time around 7 or 7:30pm that she would call and we would run through the people admitted ” [A]
    59. 59. Suggestions for Attendings Domain (n) Representative quote Easy availability (48) “ here’s my phone number… if you lose it, my pager is always on” [A] Reassure fears (50) “ I never felt like if I called him he is going to think I am weak, I didn’t feel that at all” [R] Balance supervision and autonomy (46) “ you don’t want to interfere with the residents' decisional and clinical judgment and decisions” [A]
    60. 60. Guides for Attending Supervision Domain (n) Sample strategy S Set expectations for notification(41) I want you to contact me if a patient is being discharged, transferred to the ICU, going to surgery or another service, dies, or leaves AMA. U Uncertainty (68) It is normal to feel uncertain about clinical decisions. Please do contact me if you feel uncertain about a specific decision. P Planned communication (36) Let’s plan on talking around 10pm on your call nights and before you leave the hospital each day. If you get busy or forget, I will contact you. E Easy availability (48) I am easy to reach by page, or you can use my cell phone or my home phone. R Reassure fears (50) Don’t worry about waking me up, or that calling is a sign of weakness, or that I will think your question is stupid. B Balance supervision and autonomy (46) Tailor for level of resident experience
    61. 61. Suggestions for Residents Domain (n) Representative quote Seek attending input early (28) “ [the residents’ trying to get better about calling sooner…when they are stuck and that’s the hardest part for them to figure out…” [A[ Active clinical decisions (39) “ you’re stretched thin….and when I actually went and saw that patient… she had already had the filter in place and I didn’t discuss it with the attending…” [R] Feel uncertain about clinical decisions (40) “ I am really on the fence and at the point would present to the attending why I think both” [R]
    62. 62. Suggestions for Residents Domain (n) Representative quote End of life care discussions (46) “ I want to be aware of major changes in status, someone is going to die, or about to die” [A] Transitions of care (43) “… and It was the decision whether or not to call the intensive care unit.” [R] Help with the system / hierarchy (22) “ there are certain things that they can’t do when dealing with attendings and such….” [A]
    63. 63. Resident Guide for Attending Input Domain (n) S Seek attending input early Involving your attending early can often prevent delays in care and provide quicker results. They are also legally responsible for patients. A Active clinical decisions Contact your attending if an active clinical decision is being made ( surgery, invasive procedure, etc.) F Feel uncertain about clinical decisions It is normal to feel uncertain about clinical decisions. You should contact your attending if you feel uncertain about a specific decision. E End of life care discussions These complex discussions can change the course of care. Families and patients should also know that the attending is aware of the discussion. T Transitions of care Transitions are risky for patients. Contact your attending if someone is being discharged, transferred to another service or ICU, or hospital. Y Help with the sYstem / hierarchy Despite your best efforts, system difficulties and the hierarchy may hinder care for patients. Attendings can help expedite care through direct attending involvement with consultants
    64. 64. How Will You Put this into Practice?
    65. 65. How do you prevent residents from rolling their eyes when you talk about supervision? Using a medical approach to this problem
    66. 66. Medical decision-making Uncertainty <ul><li>Very common at night especially for interns </li></ul><ul><li>Patient vulnerable (newly admitted) </li></ul><ul><li>Uncertainty breeds anxiety! </li></ul><ul><li>Few residents taught to manage decisions during uncertainty </li></ul><ul><li>Medical approach to uncertainty… </li></ul>
    67. 67. A Differential Diagnosis for Uncertainty Type Definition Case example Strategy Conceptual Do not know how to apply abstract framework to make decision Don’t know when to transfer a patient to the ICU consider algorithm or rules Seek supervision Technical Lack knowledge regarding specific content domain or task Don’t know how to do an LP or run a code Seek supervision Consultation with experts Personal Not familiar with patient or patient wishes Don’t know baseline mental status or prior course after a patient is signed over to you Retake history Reread chart Learn during handoff
    68. 68. How do our brains make decisions in the face of uncertainty? Our brains can trick us to believe the wrong diagnosis Shortcuts General idea Definition Anchoring and adjustment bias Stick with what you were told… Tend to take the first thing you hear and label that as the diagnoses and despite contradictory information Availability heuristic Going with what it was the last time you saw a case like this… Recent diagnosis are over-weighted despite being less likely Representative heuristic If it walks like a duck… Force a diagnosis to fit based on a few symptoms despite contradictory information
    71. 71. Conclusion <ul><li>The tide has turned… </li></ul><ul><ul><li>Move towards enhanced 24/7 supervision </li></ul></ul><ul><li>However, little known about effective supervision </li></ul><ul><ul><li>Especially at night </li></ul></ul><ul><li>The hidden curriculum hinders supervision </li></ul><ul><ul><li>Numerous barriers to involving the attending & existence of the hierarchy of assistance </li></ul></ul><ul><li>Education of both faculty AND residents needed </li></ul><ul><ul><li>Resident uncertainty during decision making  patient harm </li></ul></ul><ul><ul><li>SUPERB/SAFETY model to address barriers to effective supervision </li></ul></ul>
    72. 72. Future Work <ul><li>Completing a national study of program director views on supervision (with APDIM Survey Committee) </li></ul><ul><ul><li>Looking to expand to other specialties </li></ul></ul><ul><li>Exploring hospitalist role in enhancing supervision at night (with SGIM) </li></ul><ul><li>Evaluate effect of educational interventions on resident education and patient care </li></ul><ul><li>Link data on supervisory practices to patient outcomes </li></ul>
    73. 73. Jeanne Farnan, MD, MHPE U Chicago Julie Johnson, MSPH, PhD U New South Wales, AU Holly Humphrey, MD U Chicago Emily Georgitis, MD University of Chicago Alan Schwartz, PhD UIC Ilene Harris, PhD UIC David Meltzer, MD, PhD U Chicago Shannon Martin, MD University of Chicago Lindsay Dehne-Petty, MD University of Chicago Vineet Arora, MD, MAPP U Chicago
    74. 74. Jeanne Farnan Vineet Arora Questions or Ideas? For copies of our papers or tools referenced in this talk [email_address] Please visit our youtube channel: