Français

Delegation and supervision


Responsibilities of supervisors and trainees

Supervision of trainees


Case: Limited knowledge
Elderly female patient receiving bedside assistance

Background

A patient has a central venous pressure (CVP) line post-operatively. The attending surgeon asks a senior resident to see the patient and remove the line.

A medical student in clinical clerkship goes along, and when the resident is delayed outside the room, the student decides to help the patient move from a chair to the bed.

Outcome

The CVP line is in the way so the clerk disconnects it.  

The patient suffers an air embolism and severe stroke. Subsequently she and her family launch a lawsuit naming all of the healthcare providers involved, including the student.

Lessons learned

Peer experts determined:
  • It was appropriate for the surgeon to delegate the removal of the central line to a senior resident.
  • The resident did not delegate this care and so was not responsible for the harm done.
  • The student chose to perform the act but did not have the knowledge or skill to do it safely.
  • The student was therefore responsible for the harm to the patient.
Previous
Next

Case: A resident discharges a patient with enterocolitis
Hospital sign giving directions

Background

A patient presents to the emergency department (ED) with abdominal pain and diarrhea, which have been worsening over the past 9 days. The patient was previously seen twice in the ED, having been sent home each time with prescriptions for analgesic medications.
Hands clutching abdomen

Background continued

The patient is seen by a senior resident, who feels that there are no signs of an acute abdomen. The resident discusses the patient with the attending physician, indicating that the laboratory investigations are within normal limits.

The tentative diagnosis is enterocolitis of uncertain etiology, probably infectious or inflammatory in nature. The patient is discharged with instructions for oral rehydration and analgesia, and to return in 48 hours if the symptoms have not resolved.

Outcome

Several days later, the patient presents to another hospital where she is diagnosed with colonic perforation and peritonitis, secondary to ulcerative colitis.

As a result, the patient has a protracted hospitalization, and ultimately launches a regulatory authority (College) complaint.

Think about it

How might the resident and emergency physician have provided better care and potentially prevented the complaint?

Lessons learned

After reviewing the patient's record, the College's peer expert is critical that the patient was discharged after 4 hours without additional monitoring, treatment, or consultation with a specialist, given the laboratory abnormalities of mild anaemia and leukocytosis.

The emergency physician does not recall having personally reviewed the patient's bloodwork before discharge, and relied on the senior resident's oral report that the laboratory results were within normal limits. He was also not aware that the patient had already presented 2 other times to the ED.

The emergency physician participates in a collaborative resolution process with the College. He indicates that he has changed his practice and now considers whether it is necessary to confirm residents' key findings before discharging patients. The College is satisfied the physician has learned from this experience and the complaint is dismissed.

Previous
Next

Standard of care

Supervising physicians who fail to adequately supervise or inappropriately delegate tasks to a medical trainee could expose themselves to the risk of liability. They could be held liable for harm caused to a patient as a result of the trainee's actions. In the event that litigation (a civil legal action) is commenced, the court will evaluate whether the supervising physician met the standard of care when delegating the task to the trainee and supervising the performance of the delegated task.

Gavel and textbooks

To determine the applicable standard of care, the court will consider the degree of care and skill that might reasonably be expected of a supervising physician in similar circumstances. To ascertain the prevailing and approved practices at the time, the courts will generally rely on the opinions of peer experts. The experts will provide an opinion on the accepted standard(s) of care that applies to the physician in the circumstances in which the physician was practising, considering as well the specialty, training, and experience of the physician. This is often also influenced by several factors, including literature reflecting the knowledge of the profession at the relevant time and guidelines established by medical regulatory authorities (Colleges) or medical specialty organizations.

For their part, trainees will be held to the same standard as a trainee with similar training and qualifications, working in similar circumstances. All physicians, but particularly trainees must recognize their own limitations and work within them. A trainee might not avoid liability solely on the basis that the supervising physician or hospital protocol required the trainee to undertake tasks the supervisor knew or ought to have known were beyond the abilities of the trainee. All health professionals have a duty to act in the best interests of the patient—including knowing when they are unprepared to perform a task or procedure and voicing their concerns.

Checklist for staff supervision

  • Do I have sufficient understanding of the clinical situation?
  • What is the plan for care?
  • What is the trainee's level of competence?
  • Am I confident that key aspects of the plan are being followed?
  • Am I sufficiently involved?
  • Should I be there in person?

Knowing when to delegate

In every instance of delegation, the primary consideration must be the best interests of the patient. Whether or not a medical act can be delegated will depend on the physician's assessment of the trainee's competencies, skills, and experience. Assessing whether a trainee is adequately qualified may be difficult. The physician must exercise good clinical judgment in determining whether the trainee is clinically competent to perform a certain task. 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.
as part of the regular assessment of trainees can be helpful in making this determination [REF]
Ten Cate O. Entrustment as assessment: Recognizing the ability, the right and the duty to act. J Grad Med Educ 2016;8:261-2.
.

Anesthesiologist talking to 3 learners in hallway

Over time, supervising physicians should increasingly be able to grant independence to trainees and have confidence in their ability to appropriately carry out the duties delegated to them. However, supervisors should be aware of specific circumstances when more active supervision is required. This will depend on such factors as a patient's condition, the complexity of the procedure, and the level of experience and skill of the trainee. Supervising physicians must determine the appropriate level of supervision in accordance with all of these factors.

Guidelines and policies

The supervisor is responsible for the safety of the patient and support of the trainee. The supervisor must ensure the patient receives care that is delivered safely and appropriately, and that the trainee is adequately supported while they develop skills and confidence in their training environment.

Policies and procedures manual

Policies, which provide guidance concerning delegation to, and supervision of, medical trainees, have been established by hospital departments, medical schools, professional medical organizations, and provincial and territorial regulatory authorities (Colleges). These policies will be more helpful if they are covered during formal orientation sessions or at least made readily available to trainees. Likewise, supervisors should be aware of the content of such policies, which may include expectations for response time or specific clinical circumstances.