Supervision in Residency Training
"You're not alone when you are still alone."
—Idea, Michael Drayton 1600
The Residency Training Program, providing supervision at every level of postgraduate training, remains a dynamic process, its structure and practice evolving year to year. While most changes originate from within the Program itself, many of the most recent bear the influence of external factors from New York State's Department of Health Regulations, and from the University's concerns over documentation of compliance with federal Health and Human Services and Medicare regulations.
The main objective of the Program remains the optimal training of competent and safe surgeons, and in this effort, the Residency Program has adopted two intertwined approaches: first, on some services, direct apprenticeship based on a one-on-one attending-senior resident relationship, and second, the more traditional, hierarchical system of a team of residents assigned to a team of attendings on a "service."
Specifically, the rules state that, "supervision by Attending Physicians of the care provided to surgical patients by postgraduate trainees must include, at a minimum, personal supervision by the Attending Physician of all surgical procedures...the Attending Physician must be present during the critical portion of the procedures. The trainee, if credentialed, may provide the care of the non-critical portions..." The rules also stipulate that attendings supervise, defined by Webster as "direct,"preoperative assessments and daily documented post-operative visits. While there has not been significant concern in the apprenticeship system, where the attending automatically supervises, or "looks over so as to peruse"(Webster again), problems have arisen when, in the past, senior or chief residents have assumed the role of supervisors.
There is no question that attitudes within the residency ranks have changed. The chief and senior residents no longer operate in total independence as they did in the past. Thus, they no longer "learn by their mistakes,"but now learn by the mistakes of their teachers.
Does this provide greater safety for patients? Despite all best intentions, no evidence from our Program, one that has always used a graded supervisory system, supports this assumption. Now, total independence is delayed yet another year and the resulting lack of confidence in some trainees has led junior attendings to closely scrutinize and supervise all residents without regard to individual capabilities. At times, this has had a suffocating effect.
Thus, supervision within the Training Program has evolved down two paths. The first focuses on "direction,"primarily involving experienced senior attending staff and the one-on-one apprentice system. This form of supervision allows for the development of independent thinking and actual technical execution of the operation, with the attending always available for advice, yet not imposing his or her will except to assure safety and optimal outcome for the patient.
The second form of supervision tends to involve junior attendings who feel compelled to dictate every step of the evaluation, the technical procedure itself, and the post-operative care. This has been demoralizing to the senior residents and has led to efforts to reeducate the attending staff on how to teach. Junior residents have benefited from this approach in that, early in their careers, they are supervised directly by attendings, not by inexperienced albeit talented senior residents. Conversely, and unfortunately, this contributes to decreased experience and delayed maturation in senior residents who in part developed confidence and improved their technical skills by "taking juniors through cases." However, this development is still possible in the presence of "enlightened" attendings who are able to offer the requisite patience and self-discipline, abilities that need to be recognized professionally and rewarded financially.
The philosophy of residency training within the Department of Surgery is totally consistent with the RRC Program requirements that "the Attending Physician has both an ethical and legal responsibility with the overall care of the individual patient, and with the supervision of the resident involved in the care of the patient." We insist that our attending surgeons supervise ("direct") all clinical activities, and recognize that we must train them to perform this vital service at different levels of intensity, both in the clinics and the operating rooms, to allow each new generation of surgeons to grow and mature.
"So much is mine that doth with you remain, That taking what is mine, with me I take you."
—Idea, Michael Drayton 1600