Tip of the week: Tips for providing better supervision

Residency Program Insider, June 21, 2011

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The following tips will help faculty members become better at providing supervision and also eliminate many of the barriers residents face when asking for help:

  • Set clear expectations up front. Specifically outline in what circumstances you want the resident to notify you about a patient’s condition. For example, Jeanne M. Farnan, MD, MHPE, assistant professor of medicine at the University of Chicago tells residents that she wants them to call her anytime an end-of-life decision arises, or when a patient suffers an adverse event, dies, or goes to the ICU. Residents write these instructions on the sign-out sheets, and Farnan receives calls from the cross-cover residents caring for her patients, too.

    Also, establish a time every night at which the resident will call you, such as 10 p.m. Recognize that residents get busy and may forget to call. If that is the case, attending physicians should take responsibility and page the residents, says Vineet M. Arora, MD, MA, assistant professor of medicine, internal medicine associate program director, and assistant dean for curricular innovation at the Pritzker School of Medicine and the University of Chicago.
  • Be available. Attending physicians should answer all calls while on service. Some attending physicians may think that not responding or not providing residents guidance when asked promotes trainees’ autonomy, but that’s not the case. Instead, absentee attendings often cause residents to feel abandoned, Arora says.
  • Address uncertainty. Faculty members should assure residents, especially junior trainees, that uncertainty is part of education and they should not feel bad about asking for help. “Reassure residents from the beginning that there  is an expectation to call or ask about uncertainties,” says Farnan.

    Residents receive little training on how to manage uncertainty, so being explicit about what to do in these situations can facilitate appropriate supervision. Tell residents that it is normal for them to feel uncertain at times and that they should not hesitate to call with questions.
    Faculty members should also be aware of when residents feel the most uncertain, such as during rapidly escalating situations when many decisions must be made in a compressed time frame, and let residents know that it’s okay to call during those high-stress encounters, says Farnan.

    “In general, for all trainees, it’s the safety net issue. Let the house staff know that you’re there for them regardless if they have any uncertainty, no matter the situation, their level of training, or how comfortable they are with the clinical situation,” Farnan says.
  • Tailor supervision. A one-size-fits-all approach does not apply to supervision, Arora says. Faculty members need to do some reconnaissance work up front and tailor their approach in order to provide appropriate supervision. Attending physicians should consider the learner’s background and determine what his or her needs are. “I just worked with a resident who is about to enter independent practice, so it would be terrible if I was being overbearing in my supervision,” Arora explains. “What I want to do is promote a culture of autonomy and be there as a safety net. We still talked every night, but I wanted him to feel like he was the team leader.”

    However, when Arora is on service in July with the new residents, she’s more present on the ward and checks in with the team more often.
  • Make discussions worthwhile. Conversations should be a back-and-forth dialogue between the resident and attending physician. Because few attending physicians have formal training in being a supervisor, they may tend to overmanage and not cultivate the resident’s clinical decision-making skills. When attending physicians run through the list of patients and dictate what the resident should do, residents don’t learn. Instead, ask what the resident wants to do or why he or she did something a certain way. Having a real discussion helps balance the need for appropriate supervision with the residents’ autonomy. 
  • Focus on patient safety. Because residents can sometimes resent supervision, program leaders and attending physicians should focus on patient safety when supervising trainees. “We tell residents that part of learning about patient safety is working on a team, and part of working on a team is communicating with your attending and others on team,” Arora says. 

Get more supervision tips from Farnan and Arora at the 6th Annual Residency Program Management Workshop Sept 15-16, 2011 in Chicago.

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