Delegation and supervision

Responsibilities of supervisors and trainees

The role of the patient

Case: A resident assists with a hysterectomy
Laparoscopic equipment


A patient undergoes a laparoscopic-assisted vaginal hysterectomy. The chief gynaecology resident assists with the procedure, which includes suturing.


The patient comes back 2 days later complaining of nausea, vomiting, and abdominal pain. An exploratory laparotomy reveals a bowel perforation. It is determined that the bowel perforation occurred as a result of a stitch in the rectum that was placed by the resident. The patient requires a sigmoid colostomy, which is later reversed.

Lessons learned

The resulting medical-legal action is settled on behalf of the resident for the following reasons:
  • The patient was not told the resident would be performing part of the surgery.
  • The stitch went through the full thickness of the anterior rectal wall, suggesting faulty technique by the resident.
  • The resident, given the level of experience, should have been able to perform this procedure and thus the delegation was appropriate.
  • This was a technical mistake the attending gynaecologic surgeon would not likely have been able to prevent, even with close supervision.

It is important that the patient perspective be kept in mind by both supervising physicians and medical trainees throughout the learning continuum. The traditional approach of "see one, do one, teach one" has been largely supplanted by newer pedagogic strategies. For example, many trainees are learning both simple and more complex procedures through simulation-based training before performing them on patients.

Patient care must not be compromised by inexperienced or under-supervised trainees. Patients and supervisors each rely on the trainee's ability to recognize the limit of their abilities and willingness to seek assistance when necessary. This approach to learning works most of the time, but when it fails, the results can be devastating for both the patient and the trainee.

Informed consent

Physician viewing tablet with patientInformed consent has an important role in both the provision of care and in medical training. The adequacy of consent explanations is typically judged by what is known as the "reasonable patient" standard. The courts will include in their inquiry consideration of what a reasonable patient in a similar situation should expect to hear from the treating physician before consenting to that particular plan of care or treatment.

The physician who performs an investigation or treatment is ultimately responsible for ensuring the patient has given informed consent. Supervisors may delegate this duty to trainees, but should be confident that trainees have the necessary knowledge and experience to give patients adequate explanations and to answer patients' questions.

Although trainees may know about the investigation, procedure, or medication being prescribed, they should also know the risks involved with a specific patient based on their pre-existing medical conditions. If trainees are uncertain what should be included in the consent discussion, or if a patient asks a question that they cannot answer, they have a responsibility to alert their supervisor and arrange for the information to be communicated to the patient as part of confirming consent.

Informing patients about the role of trainees

Patient on stretcher signing formCanadian courts and medical regulatory authorities (Colleges) have indicated that when a significant component, or all, of a medical procedure is to be performed by trainees, the patient or substitute decision-maker must be informed of this. The information provided should include the identity of the trainees who are members of the treatment team, their stage in the educational program, as well as their degree of involvement in the patient's care. When the procedure is being performed by a trainee without direct supervision, the patient must be made aware of this fact and the patient's express consent must be obtained. Express consent is explicitly granted, either verbally or in writing. The discussion, and the patient's consent, should be clearly documented in the medical record.

In situations where the trainee has a less significant role in the medical procedure, it may not be necessary in every case to obtain express patient consent. For example, it is likely not necessary to obtain express patient consent where the trainee is observing the procedure in a teaching hospital. Where the trainee is expected to have a minimal role in the medical procedure, consideration should be given to the expectation of a reasonable patient in the circumstances, including the nature of the trainee's role and the procedure.

An examination is defined as "educational" only when it is unrelated to, or unnecessary, for patient care or treatment. An explanation of the educational purpose behind such a proposed examination or clinical demonstration must be provided to the patient and express consent obtained. Again, this consent may be given either verbally or in writing. This must occur whether or not the patient will be conscious during the examination. If express consent cannot be obtained (e.g. the patient is unconscious) and there is no clinical justification for the examination, then it should not be performed. The physician supervisor should also be confident that the proposed examination or clinical demonstration will not be detrimental to the patient, either physically or psychologically.

Addressing patients' concerns

Older woman speaking to physicianPatients may have concerns about having a medical trainee directly involved in their care. Supervisors and trainees should be prepared to respond to these concerns and also acknowledge the right of patients to refuse treatment by a trainee. This situation requires tactful communication.

In the past, patients who refused to have trainees involved in their care could often be referred to physicians working in non-teaching centres. Today, however, when patients require highly specialized care in tertiary or quaternary settings, the option of referring elsewhere is often not feasible. Patients must understand the potential implications of their refusal given that safe and effective healthcare today is provided by teams, of which medical trainees are integral members. In specific circumstances, it may be appropriate to explicitly inform the patient that the recommended treatment cannot be provided safely without the involvement of trainees, putting the onus on the patient to weigh the best option. The involvement of hospital administrators may also be required to determine how best to respond to patients' concerns.

A number of medical publications note that an increase in direct supervision of trainees results in improved compliance with clinical practice guidelines, appropriate changes in treatment plans, and better patient outcomes [REF].
Kennedy TJT, Regehr G, Baker GR, Lingard LA. Progressive independence in clinical training: A tradition worth defending? Acad Med 2005;80(10):S106-11.
 To date, there has been little literature available on how clinical supervision affects trainee learning and safe medical care in the long term. In particular, the potential decrease in trainee autonomy under the competency-based educational model might have an unintended consequence of producing clinicians with little experience in working independently. However, the alternative of not being fully aware of the trainee's ability to perform competently due to lack of observation is becoming less and less acceptable. Supervision and autonomy are not polar opposites but rather require a fine balance with safe patient outcomes as the end goal.

Pregnant patient consoled by physicianPatients should be reassured regarding the provision of appropriate delegation and adequate supervision throughout their care. Medical trainees require hands-on experience to acquire the knowledge and skills required to independently deliver quality healthcare. The future of medicine depends on the ability to provide opportunities for medical trainees to learn in a clinical environment that optimizes patient safety and respects the patient's right to be an active member of the care team.