Benefits And Harms Of “Close Supervision” Of Residents

Supervision: This single-center rigorous randomized controlled trial of level of attending supervision on a large inpatient general internal medicine service adds data to the debate about the “right” level of resident supervision.  Twenty-two attending physicians were randomized to standard practice or increased work-rounds supervision over different 2-week rotations, leading to the observation of 44 blocks.  Standard supervision (at Massachusetts General Hospital) consists of bedside presentations to the attending of all new patients and a “card-flip” on established patients following-resident-led work rounds.  In the intervention arm, attendings “joined both new patient presentations and resident work rounds 7 days a week, providing direct supervision during work rounds.”  Multiple outcomes were tracked including medical errors discovered by rigorous investigation, other patient outcomes, time-motion observations of rounds, tracking of orders and consultations, and survey responses of interns, residents, and attendings.  There were slightly but not significantly more errors in the standard supervision arm, but nearly all the errors were mild.  Only two severe errors were discovered, one in each group.  General patient outcomes, e.g. length of stay, mortality, transfer to the ICU, etc. were indistinguishable, as were number of orders and consultations.  Time-motion studies showed that work rounds were 202 minutes (!) under both conditions and that interns spoke about 10 fewer minutes during work rounds which included the attending.  The biggest differences were found in the survey data:  Interns and residents overall preferred standard supervision with large differences in the numbers agreeing that autonomy and supervision were “just right” (e.g. 97% vs. 58%) and many more agreeing that their “comfort in making independent patient care decisions improved”.  Resident and interns felt they provided very good patient care under both levels of supervision.  Attendings felt that that knew their team’s plan of care better with the enhanced supervision of work rounds.  Among attendings evaluating the periods of intensive vs. standard supervision, there were statistically borderline increases in agreement with two statements:  “we provided outstanding quality of care” and “work-life balance was poor”.   For this reviewer, the large improvement in resident autonomy, possibly leading to better care by these doctors in the future, should carry weight in this on-going discussion. — Laura Willett, MD

Finn KM, Metlay JP, Chang Y, Nagarur A, Yang S, Landrigan CP, Iyasere C. Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident Education: A Randomized Clinical Trial. JAMA Intern Med. 2018 Jun.

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