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Resident Supervision and Patient Safety

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Resident Supervision and Patient Safety

By Aaron Seth Kesselheim, MD, JD, Brigham and Women’s Hospital

Related to: Communication, Emergency Medicine, Primary Care, Obstetrics, Other Specialties, Surgery

Attending physicians based at academic medical centers or other teaching hospitals have the unique opportunity to teach and work with physicians at various levels of training (such as interns, residents, and fellows). The attending/trainee relationship, however, can have important implications for patient safety and physician liability, particularly because attending physicians overseeing trainees in providing patient care face the same malpractice risks for the care they personally deliver. (1)

In a survey of more than 800 residents (published in 2005) regarding their experiences with adverse events, 24 percent considered the event they reported to have been caused by a mistake. The single leading factor contributing to the event was “inadequate resident supervision.” (2) A second study (published in 2007) of medical malpractice cases derived from four different regions of the U.S., found that more than one-fourth of cases involved physician trainees whose role in the error was judged to be at least moderately significant. Lack of supervision was present in 54 percent of trainee-related cases. (3) These studies illustrate how the dynamics of the attending/trainee supervisory relationship play a critical role in trainee-related medical error.

Few well-defined standards of practice address issues such as how closely attendings should oversee the work of residents, how often attendings need to see patients also taken care of by house staff or fellows, and how to optimize the handoffs between attendings and trainees. In addition, the nature of the attending/trainee relationship can vary widely among medical specialties and even from attending to attending. But there are a number of steps that attendings in all specialties and settings can take to improve their supervisory relationships with trainees.

  1. Be involved in important patient care-related decisions made by trainees. Some trainees may be reluctant to reach out to attendings for reasons including fear of “looking stupid” or being reprimanded by attendings who give the impression that they do not want to be bothered. Attendings should take explicit steps to lay these fears to rest as soon as they meet their fellows and/or house staff team.

  2. Set down clear “triggers,” representing potentially important changes in patient status, that would compel trainees to call the attending. Such triggers can include specific vital sign changes or planned transfer of the patient to a higher level of care (e.g., from a general ward service to an intensive care unit). This tactic can reduce anxiety about alerting the attending during critical times in management of a complicated patient, and can lead to more rapid intervention, if necessary, from the attending. (4)

  3. Don’t overlook direct care. Attendings may need to maintain a close presence at the bedside; for example, a more complicated patient may require personal examinations from attendings at least once a day.

  4. Organize coverage if meetings or other important events arise during service time.

These steps can improve communication about patient management and help ensure that trainees know that they always have an attending-level physician to whom they can turn. Attending physicians in teaching hospital environments must work with trainees to ensure that patients receive high levels of care. Maintaining open and vibrant lines of communication with trainees is integral to that goal.


1. Kachalia A, Studdert DM. Professional liability issues in graduate medical education. JAMA. 2004;292:1051-1056.

2. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Int Med.2005;165:2607-2613.

3. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees. Arch Int Med. 2007;167:2030-2036.

4. Kowalczyk L. Hospitals try to break a deadly 'code'. Boston Globe. Nov 27 2005.


June 1, 2008
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