Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine

Update in Clinical Medical Education:Getting Supervision Right

Robert Trowbridge MD

Department of Medicine

Increased supervision of trainees will lead to improved patient outcomes

A)Agree

B)Disagree

C)Don’t know

Increased supervision of trainees will hurt educational outcomes

A)Agree

B)Disagree

C)Don’t know

Four Topics

• Evolution of Supervision

• Does increased supervision improve patient outcomes?

• Does increased supervision hurt educational outcomes?

• What makes supervision effective?

Who are these people?

Old School/New School

Kk

“Twenty-five years ago many ward attendings were senior specialists. It was considered both an honor and a duty to attend on the teaching service…being a specialist with an arcane research interest was not a disqualification.”

What is was…..

Dr. Bob Kelso

Attending month=CME?

“Often these distinguished scientists provided limited clinical input or teaching related to the patient care issues that arose on a daily basis. A handful, perhaps, should even have been offered continuing medical education credit for the month.”

Saint & Flanders, JGIM 2004

Kk

“The attending cadre is now…much more clinically engaged. Pressures to improve quality and safety, greater documentation requirements, and increasingly complex logistics of the clinical environment have upped the ante for an attending's involvement…the job of attending can no longer be handled in relatively brief visits by itinerant subspecialists.”

.

What it might be now…..

Dr. Perry Cox

Progressive Independence

• Underlying principle of medical education for decades– Competency-based medical education– Milestones project

Dreyfus Model of Expertise

Hunt, A; Pragmatic Thinking and Learning 2008

Medical School

Residency

Competent Stage

-To progress through the competent stage:

-Active decision-making-Real responsibility-Opportunity to integrate new information

In other words….INDEPENDENCE

Deliberate Practice Model

• Desire to improve performance

• Challenging activity

• Immediate & specific feedback

• Opportunity to learn from feedback and mistakes

In other words….INDEPENDENCE

Educational theory

• Zone of proximal development

• Constructive friction

Bottom Line

• Learner independence is key to improving performance

• But is true independence possible in the era of – Increasing oversight requirements,– Patient safety, and– Duty hour restrictions?

Four Topics





Answer only if you graduated medical school before 2000

I made a mistake that resulted in harm to a patient because I was inadequately supervised.

A)Agree

B)Disagree

Answer only if you graduated medical school after 2000

I made a mistake that resulted in harm to a patient because I was inadequately supervised.

A)Agree

B)Disagree

Increased supervision of trainees will lead to improved patient outcomes

A)Agree

B)Disagree

C)Don’t know

• Twenty one studies looked at patient outcomes• Six studies looked at educational outcomes• “Enhanced attending supervision of trainees…

resulted in positive changes in patient- and educational-related outcomes”

Academic Medicine (87) 428-442, 2012

Supervision and Patient Outcomes

• Procedures

• Perception of illness severity

• Changes in clinical plan

• Resource utilization/protocol compliance

Perception of Patient Illness

• Attendings consistently ranked patients as sicker than did residents

• Differences disappeared with joint patient evaluation– Residents saw patients as sicker when

seen with attending

Gennis & Gennis, JGIM 1993


• Procedures




Changes in Clinical Plan

• 1000 emergency medicine visits– Major change in 15% of visits– Life- or limb-saving change in 1.7% of visits

• 408 emergency medicine visits– Major change in care in 4%– Minor change in care in 33%


• Procedures




MMC Overnight Attending Experience

Residents Attendings

Overnight attending improved patient care

85% 90%

Overnight attending decreased medical errors

51% 55%

JGME, 2010

Bottom Line

• Increased supervision– Weak evidence to suggest improved patient

outcomes– Strong common sense to suggest improved

patient outcomes

Four Topics





Increased supervision of trainees will hurt educational outcomes

A)Agree

B)Disagree

C)Don’t know

Educational Outcomes

• Only six studies

• Four domains– Diagnostic/procedural skills– Standardized testing– Perceived autonomy– Costs

Supervision and Educational Outcomes

• Diagnostic/procedural skills

• Standardized testing

• Perceived autonomy

• Costs

Pre: attending impression of resident skill before attending evaluation

Post: attending impression of resident skill after attending evaluation

Scale: 1 (poor) to 5 (excellent)

Gennis & Gennis, JGIM 1993

Supervision and Educational Outcomes

• Diagnostic/procedural skills

• Standardized testing

• Perceived autonomy

• Costs

MMC Overnight Attending Experience

Residents Attendings

Overnight attending improved educational experience

82% >95%

Preference for overnight attending system

>95% >95%

JGME, 2010

Bottom Line

• Increased supervision– Weak evidence to suggest improved

educational outcomes– Common sense could go either way….

Four Topics





Effective Supervision

Autonomy Safety

“Clinical Oversight” Construct

• Three types of oversight– Routine oversight– Responsive oversight– Backstage oversight

• Direct patient care

Routine Oversight

• Usual and planned interactions

• Marked by monitoring and discussion

• Examples– Attending rounds– Card flip– Sign-out – Afternoon check-in

Responsive Oversight

• Occurs as the result of a trigger

• Results in higher level of involvement

• Trigger can be general or situation-specific– General triggers

• A sick patient• A concerning resident or resident skill set

Responsive Oversight– Specific triggers

• Clinical cues • Secondary sources• Discrepancies

Backstage Oversight

• Oversight of which learner may not be directly aware– Looking without being seen looking

• Little green flags

Direct Patient Care

• The “take-over”

• Patient safety issues trump education

• Still has educational value

What type of oversight is best for educational outcomes?

A) Routine

B) Responsive

C) Backstage

D) Direct patient care

E) All of the above

What’s the best mix of oversight?

So how do improve rather than just increase supervision?

Torpedos

• Lack of flexibility

• Intolerance of other’s ideas

• Indirectness

• Lack of support

• Lack of accessibility

• Evaluation instead of supervision


• Avoid being dogmatic

• Intolerance of other’s ideas

• Indirectness

• Lack of support





• Solve problems together

• Indirectness

• Lack of support






• Set clear expectations

• Lack of support







• Provide direct guidance








• Be visible







• Be visible

• Provide direct feedback

SUPERB/SAFETY

• Set notification expectations

• Uncertainty is a time to discuss

• Planned communication

• Easily available

• Reassure fears

• Balance supervision and autonomy

Hone your Responsive Oversight Trigger

• Actively consider whether you need to intervene or you want to intervene

• Consider your mix of background/routine/responsive oversight– Active calibration of your triggers

SUPERB/SAFETY

• Seek attending input early:

• Active clinical decisions

• Feeling uncertain

• End-of-life/family/legal issues

• Transitions/transfers of care

• You need help (systems/hierarchy)






• Be visible

• Provide direct feedback

• Hone & calibrate your triggers

Possible future paradigms

• Deliberate practice feedback

• Competency-based processes

• Coaching principles

Four Topics





Update in Clinical Medical Education:Getting Supervision Right

Robert Trowbridge MD

Department of Medicine

Documents

Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine