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Delegation and supervision


Responsibilities of supervisors and trainees

The physician as educator (Page 1 of 2)


Competence by Design

Competence by Design (CBD) is an initiative of the Royal College of Physicians and Surgeons of Canada, intended to improve how medical trainees are educated. The central question that the process seeks to answer is: "What do learners need to be able to do?"

Competence by Design is based on these core principles:

  1. Focusing on learning outcomes
  2. Emphasizing abilities
  3. De-emphasizing time-based training
  4. Promoting greater learner-centeredness
  5. Responding to changing societal health needs

In the past, medical trainees achieved the required knowledge and skills they needed through an apprentice-style relationship whereby a supervising physician delegated tasks and appropriate levels of responsibility to the trainee. Competency-based medical education is a more hands-on and collaborative approach where the supervisor and trainee work more closely together to ensure the required competencies are reached.

Assessment of competence

CanMEDS frameworkIn this approach, entrustable professional activities (EPAs) integrate multiple milestones that trainees must demonstrate. These milestones reflect the enabling competencies of specific CanMEDS roles. These EPAs are clinical tasks that a supervisor can delegate to a trainee once sufficient competence has been demonstrated. Assessment of competence is achieved through direct and indirect observations in the workplace.

With the role of the patient and team in educating medical trainees in mind, the processes for assessment and effective feedback need to evolve. Traditionally, the supervising physician completed an end-of-rotation evaluation of the trainee based, primarily, on their own interactions. In a competency-based model, supervisors use information gleaned from a combination of sources: their own interactions with the trainee, observations of interactions with the patient or family members, 360-degree feedback from inter-professional team members, and patient surveys.

If implemented well, Competence by Design could lead to safer medical care, better health outcomes, and reduced risks of medical-legal liability for supervisors and trainees. Countries around the world are moving to competency-based models with the support of physicians groups, patient advocates, and the legal community.

Medical-legal implications

Gavel and stethoscopeIt is always difficult to speculate, in advance, how legal liability might be decided in a specific situation. Much depends on the circumstances of each case.

That being said, a supervising physician is generally entitled to rely on trainees to carry out appropriately delegated duties. However, a supervising physician may be held liable for any harm caused by a trainee's negligence if the physician was aware the trainee was not capable of carrying out the assigned tasks or if the trainee was not properly supervised in carrying out the task. Trainees may be exposed to the risk of liability if a patient is harmed while they are performing a task that was inappropriately delegated to them.

Supervisors are responsible for assessing the appropriateness of the delegation and the necessary level of supervision based on the trainee's competence and each patient's unique clinical circumstance. Even if a trainee has been assessed as competent in a technical procedure, supervising physicians should determine the appropriate level of trainee autonomy on a patient-by-patient basis. Factors such as whether a patient is critically ill or has unusual anatomy should be weighed and considered by supervising physicians.

For their part, trainees should feel comfortable asking for help with a patient case or procedure, even if they have been deemed to be competent to perform a particular entrustable professional activity (EPA). Open communication and dialogue between the supervisor and trainee is important. Supervising physicians and trainees should discuss each patient's unique circumstances, the trainee's confidence in performing the procedure, and the potential complications.

Such a careful, reasoned approach may help to reduce exposure to the risk of liability for both supervising physicians and trainees in the event that a lawsuit arises. If it is determined that the supervisor appropriately delegated a task (and that there is a clear process for assessing and documenting competency), it will be easier to defend the position that the standard of care was met by the trainee, should a complication arise that is inherent to the procedure.