Update in Clinical Medical Education: Getting Supervision Right

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

2. Increased supervision of trainees will lead to improved patient outcomes • Agree • Disagree • Don’t know

3. Increased supervision of trainees will hurt educational outcomes • Agree • Disagree • Don’t know

4. Four Topics • Evolution of Supervision • Does increased supervision improve patient outcomes? • Does increased supervision hurt educational outcomes? • What makes supervision effective?

5. Who are these people?

6. Old School/New School

7. 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.”

8. What is was….. Dr. Bob Kelso

9. 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

10. 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.” .

11. What it might be now….. Dr. Perry Cox

12. Progressive Independence • Underlying principle of medical education for decades • Competency-based medical education • Milestones project

13. Dreyfus Model of Expertise Residency Medical School Hunt, A; Pragmatic Thinking and Learning 2008

14. Competent Stage -To progress through the competent stage: -Active decision-making -Real responsibility -Opportunity to integrate new information In other words….INDEPENDENCE

15. Deliberate Practice Model • Desire to improve performance • Challenging activity • Immediate & specific feedback • Opportunity to learn from feedback and mistakes In other words….INDEPENDENCE

16. Educational theory • Zone of proximal development • Constructive friction

17. 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?

18. Four Topics • Evolution of Supervision • Does increased supervision improve patient outcomes? • Does increased supervision hurt educational outcomes? • What makes supervision effective?

19. 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. • Agree • Disagree

20. 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. • Agree • Disagree

21. Increased supervision of trainees will lead to improved patient outcomes • Agree • Disagree • Don’t know

22. 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

23. Supervision and Patient Outcomes • Procedures • Perception of illness severity • Changes in clinical plan • Resource utilization/protocol compliance

24. 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

25. Supervision and Patient Outcomes • Procedures • Perception of illness severity • Changes in clinical plan • Resource utilization/protocol compliance

26. 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%

27. Supervision and Patient Outcomes • Procedures • Perception of illness severity • Changes in clinical plan • Resource utilization/protocol compliance

28. JGME, 2010

29. Bottom Line • Increased supervision • Weak evidence to suggest improved patient outcomes • Strong common sense to suggest improved patient outcomes

30. Four Topics • Evolution of Supervision • Does increased supervision improve patient outcomes? • Does increased supervision hurt educational outcomes? • What makes supervision effective?

31. Increased supervision of trainees will hurt educational outcomes • Agree • Disagree • Don’t know

32. Educational Outcomes • Only six studies • Four domains • Diagnostic/procedural skills • Standardized testing • Perceived autonomy • Costs

33. Supervision and Educational Outcomes • Diagnostic/procedural skills • Standardized testing • Perceived autonomy • Costs

34. 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

35. Supervision and Educational Outcomes • Diagnostic/procedural skills • Standardized testing • Perceived autonomy • Costs

36. JGME, 2010

37. Bottom Line • Increased supervision • Weak evidence to suggest improved educational outcomes • Common sense could go either way….

38. Four Topics • Evolution of Supervision • Does increased supervision improve patient outcomes? • Does increased supervision hurt educational outcomes? • What makes supervision effective?

39. Effective Supervision Autonomy Safety

40. “Clinical Oversight” Construct • Three types of oversight • Routine oversight • Responsive oversight • Backstage oversight • Direct patient care

41. Routine Oversight • Usual and planned interactions • Marked by monitoring and discussion • Examples • Attending rounds • Card flip • Sign-out • Afternoon check-in

42. 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

43. Responsive Oversight • Specific triggers • Clinical cues • Secondary sources • Discrepancies

44. Backstage Oversight • Oversight of which learner may not be directly aware • Looking without being seen looking • Little green flags

45. Direct Patient Care • The “take-over” • Patient safety issues trump education • Still has educational value

46. What type of oversight is best for educational outcomes? • Routine • Responsive • Backstage • Direct patient care • All of the above

47. What’s the best mix of oversight?

48. So how do improve rather than just increase supervision?

49. Torpedos • Lack of flexibility • Intolerance of other’s ideas • Indirectness • Lack of support • Lack of accessibility • Evaluation instead of supervision

50. Effective Supervision • Avoid being dogmatic • Intolerance of other’s ideas • Indirectness • Lack of support • Lack of accessibility • Evaluation instead of supervision