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![Page 1: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/1.jpg)
Update in Clinical Medical Education:Getting Supervision Right
Robert Trowbridge MD
Department of Medicine
![Page 2: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/2.jpg)
Increased supervision of trainees will lead to improved patient outcomes
A)Agree
B)Disagree
C)Don’t know
![Page 3: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/3.jpg)
Increased supervision of trainees will hurt educational outcomes
A)Agree
B)Disagree
C)Don’t know
![Page 4: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/4.jpg)
Four Topics
• Evolution of Supervision
• Does increased supervision improve patient outcomes?
• Does increased supervision hurt educational outcomes?
• What makes supervision effective?
![Page 5: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/5.jpg)
Who are these people?
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Old School/New School
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Kk
“Twenty-five years ago many ward attendings were senior specialists. It was considered both an honor and a duty to attend on the teaching service…being a specialist with an arcane research interest was not a disqualification.”
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What is was…..
Dr. Bob Kelso
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Attending month=CME?
“Often these distinguished scientists provided limited clinical input or teaching related to the patient care issues that arose on a daily basis. A handful, perhaps, should even have been offered continuing medical education credit for the month.”
Saint & Flanders, JGIM 2004
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Kk
“The attending cadre is now…much more clinically engaged. Pressures to improve quality and safety, greater documentation requirements, and increasingly complex logistics of the clinical environment have upped the ante for an attending's involvement…the job of attending can no longer be handled in relatively brief visits by itinerant subspecialists.”
.
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What it might be now…..
Dr. Perry Cox
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Progressive Independence
• Underlying principle of medical education for decades– Competency-based medical education– Milestones project
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Dreyfus Model of Expertise
Hunt, A; Pragmatic Thinking and Learning 2008
Medical School
Residency
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Competent Stage
-To progress through the competent stage:
-Active decision-making-Real responsibility-Opportunity to integrate new information
In other words….INDEPENDENCE
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Deliberate Practice Model
• Desire to improve performance
• Challenging activity
• Immediate & specific feedback
• Opportunity to learn from feedback and mistakes
In other words….INDEPENDENCE
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Educational theory
• Zone of proximal development
• Constructive friction
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Bottom Line
• Learner independence is key to improving performance
• But is true independence possible in the era of – Increasing oversight requirements,– Patient safety, and– Duty hour restrictions?
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Four Topics
• Evolution of Supervision
• Does increased supervision improve patient outcomes?
• Does increased supervision hurt educational outcomes?
• What makes supervision effective?
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Answer only if you graduated medical school before 2000
I made a mistake that resulted in harm to a patient because I was inadequately supervised.
A)Agree
B)Disagree
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Answer only if you graduated medical school after 2000
I made a mistake that resulted in harm to a patient because I was inadequately supervised.
A)Agree
B)Disagree
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Increased supervision of trainees will lead to improved patient outcomes
A)Agree
B)Disagree
C)Don’t know
![Page 22: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/22.jpg)
• Twenty one studies looked at patient outcomes• Six studies looked at educational outcomes• “Enhanced attending supervision of trainees…
resulted in positive changes in patient- and educational-related outcomes”
Academic Medicine (87) 428-442, 2012
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Supervision and Patient Outcomes
• Procedures
• Perception of illness severity
• Changes in clinical plan
• Resource utilization/protocol compliance
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Perception of Patient Illness
• Attendings consistently ranked patients as sicker than did residents
• Differences disappeared with joint patient evaluation– Residents saw patients as sicker when
seen with attending
Gennis & Gennis, JGIM 1993
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Supervision and Patient Outcomes
• Procedures
• Perception of illness severity
• Changes in clinical plan
• Resource utilization/protocol compliance
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Changes in Clinical Plan
• 1000 emergency medicine visits– Major change in 15% of visits– Life- or limb-saving change in 1.7% of visits
• 408 emergency medicine visits– Major change in care in 4%– Minor change in care in 33%
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Supervision and Patient Outcomes
• Procedures
• Perception of illness severity
• Changes in clinical plan
• Resource utilization/protocol compliance
![Page 28: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/28.jpg)
MMC Overnight Attending Experience
Residents Attendings
Overnight attending improved patient care
85% 90%
Overnight attending decreased medical errors
51% 55%
JGME, 2010
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Bottom Line
• Increased supervision– Weak evidence to suggest improved patient
outcomes– Strong common sense to suggest improved
patient outcomes
![Page 30: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/30.jpg)
Four Topics
• Evolution of Supervision
• Does increased supervision improve patient outcomes?
• Does increased supervision hurt educational outcomes?
• What makes supervision effective?
![Page 31: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/31.jpg)
Increased supervision of trainees will hurt educational outcomes
A)Agree
B)Disagree
C)Don’t know
![Page 32: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/32.jpg)
Educational Outcomes
• Only six studies
• Four domains– Diagnostic/procedural skills– Standardized testing– Perceived autonomy– Costs
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Supervision and Educational Outcomes
• Diagnostic/procedural skills
• Standardized testing
• Perceived autonomy
• Costs
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Pre: attending impression of resident skill before attending evaluation
Post: attending impression of resident skill after attending evaluation
Scale: 1 (poor) to 5 (excellent)
Gennis & Gennis, JGIM 1993
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Supervision and Educational Outcomes
• Diagnostic/procedural skills
• Standardized testing
• Perceived autonomy
• Costs
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MMC Overnight Attending Experience
Residents Attendings
Overnight attending improved educational experience
82% >95%
Preference for overnight attending system
>95% >95%
JGME, 2010
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Bottom Line
• Increased supervision– Weak evidence to suggest improved
educational outcomes– Common sense could go either way….
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Four Topics
• Evolution of Supervision
• Does increased supervision improve patient outcomes?
• Does increased supervision hurt educational outcomes?
• What makes supervision effective?
![Page 39: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/39.jpg)
Effective Supervision
Autonomy Safety
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“Clinical Oversight” Construct
• Three types of oversight– Routine oversight– Responsive oversight– Backstage oversight
• Direct patient care
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Routine Oversight
• Usual and planned interactions
• Marked by monitoring and discussion
• Examples– Attending rounds– Card flip– Sign-out – Afternoon check-in
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Responsive Oversight
• Occurs as the result of a trigger
• Results in higher level of involvement
• Trigger can be general or situation-specific– General triggers
• A sick patient• A concerning resident or resident skill set
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Responsive Oversight– Specific triggers
• Clinical cues • Secondary sources• Discrepancies
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Backstage Oversight
• Oversight of which learner may not be directly aware– Looking without being seen looking
• Little green flags
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Direct Patient Care
• The “take-over”
• Patient safety issues trump education
• Still has educational value
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What type of oversight is best for educational outcomes?
A) Routine
B) Responsive
C) Backstage
D) Direct patient care
E) All of the above
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What’s the best mix of oversight?
![Page 48: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/48.jpg)
So how do improve rather than just increase supervision?
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Torpedos
• Lack of flexibility
• Intolerance of other’s ideas
• Indirectness
• Lack of support
• Lack of accessibility
• Evaluation instead of supervision
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Effective Supervision
• Avoid being dogmatic
• Intolerance of other’s ideas
• Indirectness
• Lack of support
• Lack of accessibility
• Evaluation instead of supervision
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Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Indirectness
• Lack of support
• Lack of accessibility
• Evaluation instead of supervision
![Page 52: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/52.jpg)
Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Set clear expectations
• Lack of support
• Lack of accessibility
• Evaluation instead of supervision
![Page 53: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/53.jpg)
Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Set clear expectations
• Provide direct guidance
• Lack of accessibility
• Evaluation instead of supervision
![Page 54: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/54.jpg)
Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Set clear expectations
• Provide direct guidance
• Be visible
• Evaluation instead of supervision
![Page 55: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/55.jpg)
Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Set clear expectations
• Provide direct guidance
• Be visible
• Provide direct feedback
![Page 56: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/56.jpg)
SUPERB/SAFETY
• Set notification expectations
• Uncertainty is a time to discuss
• Planned communication
• Easily available
• Reassure fears
• Balance supervision and autonomy
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Hone your Responsive Oversight Trigger
• Actively consider whether you need to intervene or you want to intervene
• Consider your mix of background/routine/responsive oversight– Active calibration of your triggers
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SUPERB/SAFETY
• Seek attending input early:
• Active clinical decisions
• Feeling uncertain
• End-of-life/family/legal issues
• Transitions/transfers of care
• You need help (systems/hierarchy)
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Effective Supervision
• Avoid being dogmatic
• Solve problems together
• Set clear expectations
• Provide direct guidance
• Be visible
• Provide direct feedback
• Hone & calibrate your triggers
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Possible future paradigms
• Deliberate practice feedback
• Competency-based processes
• Coaching principles
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![Page 62: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/62.jpg)
Four Topics
• Evolution of Supervision
• Does increased supervision improve patient outcomes?
• Does increased supervision hurt educational outcomes?
• What makes supervision effective?
![Page 63: Update in Clinical Medical Education: Getting Supervision Right Robert Trowbridge MD Department of Medicine.](https://reader035.fdocuments.us/reader035/viewer/2022070403/56649f305503460f94c4a95d/html5/thumbnails/63.jpg)
Update in Clinical Medical Education:Getting Supervision Right
Robert Trowbridge MD
Department of Medicine