Strategies for Safe and Effective Resident Supervision

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

Disclosures
Grants and Contracts
ACGME
ABIM Foundation
ACP Foundation
AHRQ
NIA

Who is in the room?
Surgery (inc surgical subspecialty ortho, OHNS, plastics, NUS, urology, etc.)
Emergency Medicine, Anesthesia, or OB/Gyne
Neurology, Pediatrics, Pyschiatry, Medicine or related subspecialty
Radiology/Rad onc, Dermatology, Optho, Pathology
Other?

Outline
History, Policy & Types of Supervision
What do we know about supervision?
Review of literature to identify best practices & gaps across specialties
Understanding & improving nighttime supervision
Uncertainty & medical decision making
Introducing the SUPERB/SAFETY model

Increasing Focus on Supervision
Spent a lot of time discussing and regulating duty hours since 1980’s
Little attention has been paid to appropriate supervision
Despite calls to improve

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, "The Libby Zion Case. One Step Forward or Two Steps Backward?" 1988.

Did Supervision Get Lost?
Bell Commission
A major recommendation of the Bell Commission was to improve supervision
Ultimately, this report led to the restriction of duty hours
“ Supervision is more important than [duty] hours…”
-Dr. Bertrand Bell, 2009

Supervision & Autonomy Struggle
Traditionally programs have been evaluated by ACGME on the ability to promote resident autonomy
Graduated responsibility to prepare residents for independent practice
Tension between supervision & autonomy

Aims of Supervision
Amongst medical educators
Promote professional development
Ensuring patient safety
Desired features of supervision
Normative = highlighting standard of care
Formative = feedback for improvement
Supportive = reflection & assistance
Little guidance as to the nature/extent of supervision to be provided
Med Educ 2000; 34:827-840,Med Educ 2005; 39: 696-703

Implications of Supervision
Patient Safety
Prevent adverse outcomes
Institutional liability
Medical education
Train competent physicians
Re-imbursement
HCFA/CMS guidelines
JAMA 2004; 292 (9): 1051-1056, Lownsbury v VanBuren

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

Specialty-specific Policy: OB
“ 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 .”
www.acgme.org Program Requirements Ob/Gyn

Specialty-specific Policy: Surgery
“ 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.”
Current RRC guidelines in IM DO NOT detail what constitutes faculty supervision
In contrast to other detailed RRC’s
http://www.acgme.org Program Requirements Gen Surgery

Challenges: Defining Effective Supervision
“ If you were to ask a dozen IM faculty what constitutes adequate resident supervision, you would probably get as many different answers…”
Casner, 1995.

Other policies
State-dependent legislation
Illinois State Law
(225 ILCS 60/) Medical Practice Act of 1987
“ 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”
Academic center-dependent guidelines

Recent Technological Advances in Supervision
Telemedicine and the eICU
Online tools
Video conferencing

Recent Recommendations
12/08 IOM Report on duty hours
Recommends augmenting resident supervision
24/7 on-site attending supervision for ALL GME programs
Impact of attending supervision on resident education & patient outcomes?

What do we know about supervision? Review of literature to identify best practices & gaps

Existing Evidence
Systematic review of the current literature to
Describe effect of clinical supervision interventions on residency education & patient outcomes
Multi-specialty focus
Where are the gaps?

Standardized Data Abstraction
Design, type of supervision
Clinical setting, supervisor & trainee role, specialty, outcomes
Performed by three authors

Study Quality: MERSQI
Medical Education Research Study Quality Index
Developed and validated by Reed et al.
Reed et al. JAMA 2007, Reed et al. JGIM 2008.

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

Supervision Study Summary
All but 1 study suggest that enhanced attending supervision in already supervised activities (clinic, surgery, etc.) improves outcomes
Interestingly, more studies actually (11) examined patient outcomes
only 5 examined educational outcomes

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

Night-time Supervision
Qualitative comments:
“ [the presence of the attending] is more often symbolically satisfying, than a real help”

So What Do We Know?
Enhanced attending supervision during routinely supervised activities may improve patient outcomes & resident education
Only 1 study to date examining effects of enhanced night-time attending supervision
Unclear impact on meaningful outcomes

Understanding and improving nighttime supervision Supervision theater

http://www.youtube.com/user/MergeLab#p/u/3/mEsikH6PdDA

Debriefing
What types of barriers or facilitators did you observe?
Environment
Cultural
Communication
Any others?

The University of Chicago Experience… The good, bad and ugly of nighttime supervision

Competing Factors Resident Attending Autonomy Hidden Curriculum Clinical expertise Billing pressures Research/clinical obligations Lack of formal supervision training Liability, Institutional culture Patient Care

Methods: Setting
January through November 2006
In-house call every 5 th night
10 new admissions per call night
Focus on attending-resident relationship
Attending Physician General Internal Medicine/Subspecialty Senior resident PGY-2/3/4 Categorical or preliminary intern Categorical or preliminary intern

Survey
General supervision practices:
“ There were clinical scenarios for which I wished I would’ve been contacted earlier”
Attending-level notification for:
Diagnostics (performing LP)
Therapeutics (IV antibiotics)
Transfer of care (ICU transfer)
Sentinel/adverse events (cardiac arrest)
Farnan, et al. Amer J Med. 2009

Interviews
Critical incident technique used to solicit examples of ineffective supervision
Appreciative inquiry used to solicit examples of effective supervision
“ What would you consider to be effective supervision?”
Flanagan JC. Psychological Bulletin. 1954; 51.4:327-359 Appreciative Inquiry commons. http://appreciativeinquiry.case.edu/

Attendings & Residents Differ on Perceptions of Supervision
Response rate
44/50 (84%) attendings & 46/50 (92%) residents (38% hospitalists)
81% of attendings vs. 91% of residents reported contact [personal or telephone] at least once per call night
Perception of frequency that attending input changed patient plan of care:
21% (attendings) vs. 10% (residents) p=0.001, [0.13,0.18]

Attendings wished to be contacted earlier regarding patient issues than residents desired to contact them (z=2.882, p=0.004)
Attending Resident # of respondents

Disparity in Supervision Preferences
Attendings expressed a greater desire to be notified than residents wished to notify them for the following:
Receiving transfer pt from ICU (p=0.0009)
Receiving transfer pt from outside facility (p=0.001)
Initiation of vaso-active medications (p=0.02)
Initiation of IV antibiotics (p=0.003)

Similarities in Supervision Preferences
Residents and attendings agreed that immediate notification was warranted for:
ICU transfer of an existing patient
Cardiac/respiratory arrest
House-staff personally performing an invasive procedure

Models of Supervision
“ Micro-manager”
“ Absentee”
Characteristics of effective supervisors:
“ Safety net”
“ Teacher”
“ Mentor”
“ Role model”
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

Conclusions
Attending desire to supervise is greater than resident desire to seek supervision
Attending physicians wish to be contacted earlier and more often
Two extreme models of attending clinical supervision observed
Both with detrimental effects on residents
Attending-level education needed??

If residents are not contacting their attending at night, how are they making decisions? Medical decision-making during uncertainty

Aims
Describe resident uncertainty during times of clinical decision-making
Identify resident response to uncertainty
Specifically, when did residents seek (or not) attending input at night
Describe impact of resident uncertainty on delivery of patient care

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

Uncertainty & Patient outcomes
18 discrete critical incidents identified
10 discrete adverse outcomes identified
6 involving delay in indicated procedure or diagnostic testing
2 suffered procedural complications
2 suffered cardiac arrest/death

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)

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*

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

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

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

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

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

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

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

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”

Implications
Residents are not pursuing supervision at potential times of patient vulnerability
Possible contributor to adverse events
Numerous barriers – at both the attending and resident level – prevent residents from seeking supervision
Hierarchy of assistance embedded in the hidden curriculum within residency training
Residents need to be educated on the importance of attending-level supervision

Strategies to teach Supervision to Attending and Resident Physicians The SUPERB/SAFETY Model

Education at BOTH levels
Formal training in effective supervision practices needed:
Attending education regarding the balance between autonomy and supervision
Resident education regarding:
Attending’s responsibility to supervise
Importance of recognition and management of uncertainty

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]

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]

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

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]

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]

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

How Will You Put this into Practice?

How do you prevent residents from rolling their eyes when you talk about supervision? Using a medical approach to this problem

Medical decision-making Uncertainty
Very common at night especially for interns
Patient vulnerable (newly admitted)
Uncertainty breeds anxiety!
Few residents taught to manage decisions during uncertainty
Medical approach to uncertainty…

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

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

PARIS IN THE THE SPRING

Conclusion
The tide has turned…
Move towards enhanced 24/7 supervision
However, little known about effective supervision
Especially at night
The hidden curriculum hinders supervision
Numerous barriers to involving the attending & existence of the hierarchy of assistance
Education of both faculty AND residents needed
Resident uncertainty during decision making  patient harm
SUPERB/SAFETY model to address barriers to effective supervision

Future Work
Completing a national study of program director views on supervision (with APDIM Survey Committee)
Looking to expand to other specialties
Exploring hospitalist role in enhancing supervision at night (with SGIM)
Evaluate effect of educational interventions on resident education and patient care
Link data on supervisory practices to patient outcomes

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

Jeanne Farnan jfarnan@medicine.bsd.uchicago.edu Vineet Arora varora@uchicago.edu Questions or Ideas? For copies of our papers or tools referenced in this talk [email_address] Please visit our youtube channel: http://www.youtube.com/mergelab

Strategies for Safe and Effective Resident Supervision

by Vineet Arora on Jun 05, 2010

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