Little information is available on how teaching outcomes involving academic hospitalists and resident physicians affect patient safety and error rates—particularly under duty-hour restrictions on residents by the Accreditation Council for Graduate Medical Education (ACGME).
But data show that when medical errors occur they are often connected with residents’ errors in judgment, lack of technical competence, inadequate supervision by senior physicians, and a breakdown in teamwork.1 In a study of 889 cases resulting in error and injury, 240 involved trainees with at least a “moderately important” role. Among the findings:
- Residents were involved in 208 of those 240 cases;
- 168 of the cases occurred in the inpatient setting;
- 80 of the cases involved obstetrics-gynecology residents, and 45 involved general surgery residents;
- Trainees “lacked technical competence or knowledge” of diagnosis in 67 cases; and
- Attending physicians were involved in 106 supervision failures.
Based on this information, how can academic hospitalists best supervise residents to reduce errors and optimize patient safety and treatment while enhancing residents’ training and satisfaction? Academic hospitalists across the United States grapple with this question daily. And a few have come up with ways that meet the needs of patients and residents.
—Eric Siegal, MD, regional medical director, Cogent Healthcare, Madison, Wis.
Oversight vs. Hindsight
Reflecting on his residency, Eric Siegal, MD, a regional medical director with Cogent Healthcare in Madison, Wis., and chair of SHM’s Public Policy Committee, says he recalls times when he did not receive sufficient oversight from senior physicians. Consequently, he and his patients suffered, he says.
“We were thrown into things with little or no supervision, and we were told to sink or swim,” he says. “The good news is that we learned a ton on our own. The bad news is we hurt people in the process. So, the question is how do you walk a line of creating house staff who are autonomous and competent while protecting the patient?”
As an attending physician at the University of Wisconsin, Dr. Siegal says he gave his residents autonomy to make decisions. But there were things he did not let them do alone or without first asking. “The obvious thing was procedures,” he notes. “When residents did procedures, I was standing right there next to them. The extent to which I got involved was entirely dependent on the extent to which the resident was competent.”
Likewise, Alpesh Amin, MD, MBA, professor and chief, division of general internal medicine and executive director of the hospitalist program at the University of California, Irvine, says he gives residents oversight but doesn’t hover. “Otherwise they’re not learning from experience by only doing what someone else tells them to do,” he says. “But without oversight, you don’t prevent errors.”
Dr. Amin, a member of SHM’s Board of Directors, says that as an attending he begins the month with an orientation, reviewing items that help prevent hospital errors. For example, he urges residents before giving medicine to think about possible renal insufficiency and drug interactions. He says he also stresses the importance of preventive techniques.
Developing a system that allows residents to feel comfortable approaching their attending with questions is also vital, says Dr. Amin. Meanwhile, the attending needs to feel he can ask residents pointed questions, yet allow them to think things through.