Standards for Residents Same as Senior Physicians

Some residents, fellows, and even the physicians who supervise them may assume that physicians-in-training are held to a lower standard of care than attendings. But Legal Editor Frank Reardon discusses a Rhode Island Supreme Court case that joins other decisions across the country holding residents to the same standard as attendings.

While they are residents, physicians practice medicine under a license that requires them to work in concert with an attending physician. In Baccari v. Donat, the Supreme Court of Rhode Island considered what type of jury instructions should be given at trial regarding the standard of care expected from resident physicians.

The plaintiffs, Stephen and Dolores Baccari, filed a medical malpractice case alleging that negligent medical care caused serious injury to both of Stephen's arms, eventually requiring amputation of his left arm above the elbow. Among the defendants named in the lawsuit were resident physicians and the Rhode Island Hospital. At the end of the trial, the jury returned a verdict attributing no liability to any of the defendants. But the plaintiffs appealed, claiming the jury instructions on the standard of care were ambiguous, confusing, and contradictory.

The trial court judge gave three instructions to the jury that became the basis for the appeal. In one instance, the judge said the resident physicians were required to exercise the same standard of care applicable to "physicians with unlimited licenses to practice." In the second, she told the jury that residents were to be held to the degree of skill and care "which was possessed by the average resident." And in the third, the judge instructed the jury that the physicians were required to exercise "the degree of care and skill that is expected of a reasonably competent practitioner in the same class to which he or she belongs acting in the same or similar circumstances."

The Rhode Island Supreme Court agreed that, at the time the judge gave this instruction, it was unclear whether the term "same class" was meant to refer to resident physicians or attending physicians with unlimited licenses. They agreed that the instruction was contradictory and could have misled a reasonable jury into believing that residents were subject to a lesser duty of care than physicians with unlimited licenses. As Rhode Island holds residents to the same duty of care as other physicians, the Court found this flaw to be significant and, unfortunately for the defendants, sent the case back for re-trial.

The 1999 Rhode Island case is consistent with other jurisdictions. In the 1994 Massachusetts case of St. Germaine v. Pfeifer, the Massachusetts Supreme Judicial Court likewise held that the standard of care for residents is the same as for other physicians. In its decision, the SJC quoted an Ohio decision that upheld the following jury instruction:

"The standard of care in a medical malpractice case involving a first year resident was...that of a reasonably careful physician...not that of interns or residents."

The Massachusetts Court also cited and concurred with an Indiana decision holding that interns and first year residents are "practitioners of medicine required to exercise the same standard of care applicable to physicians with unlimited licenses to practice."

Defense attorneys in Rhode Island and Massachusetts can still admit evidence to show that the resident physicians were practicing medicine under a limited license at the time of any alleged negligent treatment. However, juries will be instructed that residents are required to conform to the standard of care of fully licensed attending physicians.

Physicians founded the teaching hospital model on the premise that care delivered by residents with faculty back-up meets the highest standard, whether actually provided by the residents or the faculty. In this instance, the law and conventional wisdom in the medical education community appear to agree.

A number of important cases have held that attendings are not responsible for the acts of other health care professionals. But they must assign tasks appropriate to the individual's range of capabilities and provide adequate supervision. Where a resident is permitted to perform a procedure or oversee a course of treatment, these cases show that the patient and the courts will expect that the resident is at a level of training and experience to adequately do so.

In a 2016 review of these standards, attorney John J. Barton of Barton, Gilman explained: This holding(Baccari v. Donat) has been revisited once in substance by the Rhode Island Supreme Court. In Gianquitti v. Atwood Medical Associates, Ltd, the court clarified the holding to a degree. There, the Court noted that the Baccari opinion “did not define or address an intern’s or resident’s duties under the circumstances present in a particular case.” On that basis, the Court reiterated that in general, a physician (including residents, fellows, and attendings) is held to a duty of care “that is expected of a reasonably competent practitioner under similar circumstances.” In addition, he stated there have been no opinions which have chipped away or re-defined the Massachusetts opinion of St. Germaine v. Pfeifer.