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Delegation and supervision

Responsibilities of supervisors and trainees

Importance of communication (Page 1 of 2)

Case: Delayed diagnosis of compartment syndrome
Damaged bicycle in park


A young teenager is brought to the emergency department after being struck by a car while riding his bicycle. He is diagnosed with a comminuted displaced proximal tibial fracture (Salter-Harris IV) by the emergency physician.

Background continued

The patient is seen by the orthopaedic resident, who discusses the case with the attending orthopaedic surgeon. They review the patient's X-rays together and determine that the patient will ultimately require open reduction and internal fixation (ORIF).

In the meantime, the surgeon asks the resident to perform a closed reduction and apply a cast. Given the amount of leg swelling, the resident raises the possibility of compartment syndrome, which the surgeon promptly dismisses.

Surgeons performing an operation

Surgical procedure

The patient undergoes an ORIF procedure, at which time a circumferential cast is applied. At the time of surgery, the attending surgeon again expresses his opinion that there are no clinical signs of compartment syndrome. The patient is transferred to the ward for post-operative care.

Post-operative course

Later that same evening, the patient complains of severe pain and is unable to move his toes. The resident is notified and partially splits the cast, resulting in some relief of the patient's pain. When the nurse calls again about the patient's pain, the resident informs her that the patient will be reassessed by the team in the morning and to notify the pain service for additional analgesic orders. The resident hands over the next morning to the resident on call.

The patient continues to complain of severe pain, and the on-call resident performs a full splitting of the cast later that day. The nurses express their concern that the patient has not been able to move his toes since the surgery. The on-call resident takes no further action, believing that the orthopaedic surgeon is already aware of this information.


On post-operative day two, the attending surgeon reviews the patient in person, is concerned about the possibility of compartment syndrome and brings the patient back to the operating room. The patient undergoes a four-compartment fasciotomy, and ultimately requires skin grafting and physical rehabilitation.

Think about it

What communication issues may have contributed to this outcome?

Lessons learned

The resulting medical-legal action is settled on behalf of the surgeon and residents for the following reasons:
  1. The surgeon failed to properly supervise the residents, given the high risk of the patient developing compartment syndrome.
  2. The nurses conveyed their concerns about the patient to the residents, who failed to communicate critical information about the patient's condition to their supervisor.

Open communication

Open communication is the key to building a strong relationship between supervisors and trainees, and to ensuring that the education provided is of the utmost benefit. Supervisors' supportive communication and evident willingness to help trainees will make trainees feel comfortable to voice any concerns they have about a particular task or procedure.

It is important for the medical trainee and supervising physician to remember that they likely each owe an independent duty of care to the patient. This duty includes the obligation to act in the patient's best interests, refer the patient to another healthcare professional if needed, communicate pertinent information necessary for ongoing care, and attend to the patient as long as good medical practice warrants. This duty of care is fundamental to patient-centred medical training.

Trainees should feel free to clarify instructions they receive and ask supervisors for help or assistance when needed. Ideally, the expectation as to when to call for help should be discussed when supervisors and trainees first work together, whether at the start of a clinical shift or during a formal orientation to a clinical service.

Challenges for trainees

Resident in contemplationMedical trainees are entering a profession with its own set of values, beliefs, practices, and expectations. As such, trainees often feel that they must conform to the pre-set personae of their medical specialty. They are evaluated by how they "fit in" with their healthcare team and superiors. In addition, the volume and pace of their workload may often be perceived as incompatible with compassionate and patient-centred care.

While medical trainees may be able to recite the published literature and recall long lists of evidence-based theory, they may have little experience in applying this knowledge to real-life patient care. As a result, trainees often feel anxiety, stress, fatigue, and self-doubt. This can compromise their ability to make decisions, ask for help, and provide safe medical care. They may be afraid to show any weakness and worry about asking for help for fear they will be dismissed by their peers and supervisors.

Not infrequently, medical trainees have difficulty accurately judging their level of competence in performing certain procedures or may even over-estimate their abilities. Furthermore, trainees may find themselves in situations where they are expected to supervise more junior residents or medical students before they feel confident to do so. The use of entrustable professional activities (EPAs)
Entrustable professional activity (EPA):  A clinical task that a supervisor can delegate to a trainee once sufficient competence has been demonstrated.
in assessment can guide trainees, as well as supervisors, to judge readiness to provide care and the required level of supervision [REF]
The Royal Australian and New Zealand College of Psychiatrists [En ligne]. Melbourne (AU): RANZCP. Entrustable Professional Activities (EPAs) [cité le 29 juin 2017]; [environ 3 écrans]. Disponible : https://www.ranzcp.org/Pre-Fellowship/2012-Fellowship-Program/Assessment-overview/Entrustable-Professional-Activities.aspx
. This includes the appropriateness of supervising more junior trainees.

It is the obligation of trainees to speak up at any time they find themselves in a situation where they are uncomfortable or doubtful of their ability to provide safe medical care to a patient.

Challenges for supervisors

Physician holding file folderAlthough the framework for the supervision of medical trainees may be well established in theory, in practical terms, the appropriate delegation of tasks and providing adequate teaching can prove challenging for many physician supervisors. Effective supervision involves skills that are different from clinical competence.

Supervising physicians are teachers and mentors, guiding trainees by observing their performance, providing feedback, imparting clinical judgment, monitoring progress, determining competence, and displaying professionalism. For these reasons, trust between a supervisor and trainee is paramount.