Supervising Residents

1. Supervising Residents Chris Watling MD, MMEd, FRCPC Associate Dean Postgraduate Medical Education

2. Principles • Residents need hands-on experience • Residents and supervisors must act in the best interests of the patient • Every patient must have a medical staff person ultimately responsible for his or her care

3. The learning environment • Must be SAFE • For residents • For patients • Should FACILITATE residents acquiring knowledge and skills set out in their objectives

4. Delegating Tasks • Impractical for supervisors to oversee every decision and action made by residents BUT… • Ensure residents are only given tasks within their competence

5. Delegation • Can delegate some supervisory tasks to senior residents BUT • Cannot delegate the ultimate responsibility for the patient as MRP

6. Be Aware Of… • Learning objectives • Resident’s skill/training level • Residents with difficulty identifying their limitations • Residents unable to provide safe care because of • Stress • Fatigue • Patient overload

7. Supervisory Responsibilities • Ensure patients are informed of trainees’ status • BE AVAILABLE when urgent judgment is required • Respond to pages • Return to hospital if needed • Ensure, with colleagues, a call schedule that provides residents with 24/7 supervision

8. Supervisory Responsibilities • Confirm admission documentation within 24 hours • Review acutely ill patients at least daily • Orient residents to their roles and responsibilities • Ensure residents are competent before delegating procedures

9. Role Modeling • Model professional conduct • Provide support and guidance in managing conflict

10. Resident Responsibilities Residents must • Know their limits • Let supervisor know if they are asked to perform tasks beyond their abilities • Inform patients of their status and who the attending is • Inform PD if supervision is inadequate

11. Residents must inform supervisor if… • Significant change in patient condition • Dx/management in doubt • Procedure or therapy that may cause harm is to be undertaken • Patient referred from another service • Patient is to be referred to another service • Patient is to be d/c from ER or hospital

12. Evaluation of Residents • Linked to objectives • Based on CanMEDS roles • Medical expert • Communicator • Collaborator • Health Advocate • Manager • Professional • Scholar

13. Why Evaluate Learners? Evaluation can determine… • Annual promotion • Examination readiness • Choice of candidates for advanced training AND • Can serve society

14. Evaluation and Learning • Evaluation should provide direction and motivation for learning

15. In-Training Evaluation is Problematic • Longstanding validity and reliability concerns with ITE • Barrows (1986) • Direct observation of students limited and random • Clinical performance assessment often based on oral or written case presentation

16. Evaluation • Direct observation of residents is key • Credibility limited if evaluation not based on observation

17. Engagement (Watling et al, 2008) • Central to value residents place on in-training evaluations • External influences on engagement • Timeliness • Credibility • “Constructiveness” • Internal influences on engagement • Receptivity • Reliance on self-assessment

18. ITERs • Timely • Specific • Narrative comments valued • Constructive advice • Grounded in clinical work

19. Feedback Bing-You and Patterson (1997) • Residents valued feedback that was… • Well-timed • Private • Fostered development of action plan • Residents might reject feedback if sender not seen as credible • Level of respect • Content of feedback • Method of delivery

20. Feedback is Not a One-Way Street • Perceptions of evaluators may differ considerably from those of trainees • Sender-Liberman (2005): • 90% of surgeons felt they were “often or always” successful in providing effective feedback • 16% of residents agreed! • Claridge (2003): • 61% of faculty scored their teaching abilities significantly differently from how residents scored them

21. A Shared Aversion… • Teachers may avoid giving negative feedback because… • Students may be hurt • Student-teacher relationship might be damaged • Low ratings might demotivate students • Remediation might not be available (Ende 1983, Daelmans 2006)

22. Failure to Fail Dudek (2005) identified barriers to faculty failing trainees: • Lack of documentation • Lack of knowledge of what to document • Anticipation of an appeal • Lack of perceived remediation options

23. Faculty Engagement (Watling, 2010) Barriers to faculty engagement in the in-training evaluation process: • Time constraints • Limited direct observation opportunities • Inconsistency in approach to ITE • Lack of continuity between rotations • The challenge of giving negative feedback while avoiding harm to learners

24. The Road Ahead Evaluation of trainees is not simple! • Complex interpersonal dynamics are involved • Characteristics, attitudes, and behaviour of participants are highly influential

25. Effective Feedback is Necessary • Ende (1983) warned that a consequence of inadequate feedback during residency is that residents develop a system of self-validation that excludes evaluation from external sources Is this a problem? YES. Physicians are poor self-assessors! (Davis 2006)

26. Some Practical Suggestions Regarding Feedback Things to do… • Focus on the task • Be specific and clear • Provide elaborated feedback, but in manageable units • Facilitate a culture of feedback • Establish a trusting relationship with the learner

27. Feedback: Things to Avoid • Normative comparisons • Threats to self-esteem • Interrupting the learner with feedback if learner is actively engaged in problem-solving • Excessive use of praise • System fragmentation

28. SUMMARY • Be aware • Be available • Be open • Communicate clearly • Rise top the challenge of evaluating residents constructively