An article for physicians by physicians
Originally published September 2008
Risk management considerations for supervising physicians, and supervised residents and other trainees.
Of interest to all medical trainees and their supervising physicians
Medical trainees require hands-on experience to acquire the knowledge and skills necessary to independently deliver quality health care. Such experience has traditionally been achieved through an apprentice-style relationship whereby a supervising physician delegates tasks and appropriate levels of responsibility to the trainee. Problems can be minimized if the delegation is appropriate and the supervision of the trainee is adequate.
Both the trainee and supervising physician owe a duty of care to the patient. This duty includes the obligation to act in the patient's best interests, refer the patient to another health professional if needed, communicate pertinent information necessary for ongoing care, and attend to the patient as long as good medical practice warrants.
In the event of litigation, the supervising physician will be held to a standard of care that could reasonably be expected of a normal prudent physician in the circumstances. The trainee will be held to a standard of care appropriate to his or her level of training, experience and the situation. In addition, the supervising physician could be held liable for any harm caused by a trainee's negligence if the physician inappropriately delegated the task or did not properly supervise the trainee during the task.
The following cases illustrate how the Courts have viewed the responsibilities of the medical trainee and the supervising physician in specific clinical circumstances.
A 70-year-old male patient with a past history of a myocardial infarction developed debilitating angina despite aggressive medical management. It was determined he would benefit from a coronary artery bypass graft (CABG) procedure to treat his occluded right coronary artery. The patient consented to the surgery after discussing the risks with the cardiovascular surgeon. The surgeon arranged for the resident to be his assistant.
The senior resident had completed her general surgery residency and one year of cardiothoracic surgery. She had assisted this cardiovascular surgeon 60 to 80 times prior to this procedure and had performed at least 12 to 18 midline sternotomies.
The resident performed the midline sternotomy while the cardiovascular surgeon harvested the patient's saphenous vein. During the sternotomy, the oscillating saw blade inadvertently transected four costochondral cartilages.
The resident immediately notified the staff surgeon who assessed the patient and determined it was appropriate to continue with the planned bypass surgery. The surgery was completed without further incident.
The patient had a difficult postoperative hospital course due to non-cardiac chest pain. Following discharge, the pain, diagnosed as costochondritis, continued to interfere with his daily activities.
The patient began a legal action naming the resident and the cardiovascular surgeon, alleging the surgeon inadequately supervised the resident, and the resident was negligent in performing the midline sternotomy.
The judge in this case commented:
A fourth-year resident pursuing additional training in cardiovascular surgery generally has the skill and experience to do a sternotomy.
This specific fourth-year resident had the experience and skill to perform the midline sternotomy as she had done so many times before.
It was appropriate for the staff cardiovascular surgeon to delegate the sternotomy to a senior resident in this case.
The surgeon appropriately delegated the sternotomy to this resident who he had worked with previously.
The surgeon provided appropriate supervision to the resident.
The resident was not negligent in performing the midline sternotomy.
The action was dismissed.
A 56-year-old diabetic male with a history of cardiac problems, including previous coronary bypass surgery, presented to the emergency department following one hour of burning chest pain associated with nausea and an acidic taste in his mouth. He believed he was having a heart attack as the pain was similar to his myocardial infarction 10 years earlier.
The patient was quickly assessed by the emergency physician and referred to the second year postgraduate student (PGY2) in cardiology. After a careful history and physical examination, review of repeated ECGs and cardiac markers over an eight hour period, the resident determined the patient's chest pain was due to dyspepsia. Although the ECGs showed evidence of previous heart damage, there was no indication of acute ischemia. Cardiac markers remained normal. The patient had an iron deficiency anemia and a history of high daily alcohol intake, which led the resident to consider the pain to be gastrointestinal in origin. The PGY2 cardiology resident discussed the patient's condition with the on-call staff cardiologist by telephone. The patient was subsequently referred to the internal medicine service.
A PGY3 internal medicine resident assessed the patient and reviewed the available information, and determined the patient's chest pain was most likely due to reflux esophagitis. He discussed the patient with the attending staff internist by telephone, who concurred with the diagnosis. The patient was prescribed a proton pump inhibitor and was discharged home to follow up with his family physician.
The patient was seen two weeks later by his family physician. The medication had provided some relief of the chest pain but he had developed shortness of breath. A repeat ECG, which showed changes from the previous ECG in the medical record, indicated heart damage of indeterminate age. Due to the shortness of breath and the changed ECG, a referral was made to a cardiologist; however, the patient unfortunately died three days later, prior to being seen by the cardiologist.
The family began a legal action and alleged the staff cardiologist and internist should have come to the hospital themselves to examine the patient or should have admitted the patient to the hospital for further observation. The residents were not named in the legal action.
A medical expert for the family believed the staff physicians "gave up the opportunity for first-hand information" by not examining the patient themselves. Experts for the defence noted that telephone consultations with supervising physicians are routine in training programs. The supervising physician must determine whether to attend the patient personally based on the information received by telephone and their knowledge of the resident's ability.
The judge in this case commented that:
This case was not too complex to be handled by the supervising staff via telephone, and the decision to attend was a matter of judgment. The supervising physicians considered both the complexity of the patient's medical condition and their knowledge of the individual resident's skills before deciding to rely on the telephone consultations.
Both staff physicians had worked extensively with the residents they were supervising and had full confidence in their abilities.
The attending staff committed no negligence in the supervision of the residents.
The action was dismissed.
While in this case the care provided was not found to be negligent, supervising physicians are reminded that if a patient experiences an adverse outcome the advice and support provided to the resident over the telephone will likely be closely scrutinized.
Risk management considerations
Academic programs expect trainees to accept greater responsibility and autonomy with increasing training and experience. The Courts have commented that it makes intuitive sense to have residents gradually left on their own over the course of training. Policies have also been established by professional medical organizations and provincial/territorial regulatory authorities (Colleges), which provide guidance concerning delegation to, and supervision of, medical trainees.
Responsibility of supervising physicians
In legal actions, the Court generally considers whether the delegation, supervision and support provided by the supervising physician were reasonable in the circumstances. Supervising physicians should therefore consider the following:
Is the task appropriate to delegate to an individual with the trainee's level of training?
Does this specific trainee have the required knowledge, skill and experience to perform the task?
What degree of supervision is required?
Has the patient been informed of the educational status of the trainee?
When consulting with residents over the telephone, supervising physicians may additionally want to consider the following:
Do I have sufficient understanding of the patient's clinical presentation to offer an opinion on the diagnosis and management?
Have I sufficiently questioned the resident to develop an appropriate management plan for the patient?
Would the patient's condition or the needs of the resident require me to personally attend the patient?
Have I taken steps to determine whether the resident requires additional support to meet the current workload demands?
Responsibility of trainees
In legal actions, the Court generally considers whether the trainee performed at a standard which could reasonably be expected. Trainees and residents should therefore:
Recognize the limits of their knowledge.
Exercise caution and consider their inexperience.
Notify their supervisors of their knowledge, skill and experience with the delegated task.
Keep the supervisor informed of their actions.
Inform patients of their status as medical trainees.
Open and supportive communication by the supervisor and readiness to help the trainee will allow the trainee to voice any concerns about a task. The trainee should feel free to clarify instructions, voice concerns and ask the supervisor for help.