Supervising Residents

1. Supervising Residents MithuSen MD FRCPC Postgraduate Medical Education

2. Principles • Residents need hands-on experience • Residents and supervisors must act in the best interests of the patient • Every patient must have a medical staff person ultimately responsible for his or her care

3. The learning environment Must be SAFE For residents For patients Should FACILITATE residents acquiring knowledge and skills set out in their objectives

4. Delegating Tasks Impractical for supervisors to oversee every decision and action made by residents BUT… Ensure residents are only given tasks within their competence

5. Delegation Can delegate some supervisory tasks to senior residents BUT Cannot delegate the ultimate responsibility for the patient as MRP

6. Be Aware Of… Learning objectives Resident’s skill/training level Residents with difficulty identifying their limitations Residents unable to provide safe care because of Stress Fatigue Patient overload

7. Supervisory Responsibilities • Ensure patients are informed of trainees’ status • BE AVAILABLE when urgent judgment is required • Respond to pages • Return to hospital if needed • Ensure, with colleagues, a call schedule that provides residents with 24/7 supervision

8. Supervisory Responsibilities • Confirm admission documentation within 24 hours • Review acutely ill patients at least daily • Orient residents to their roles and responsibilities • Ensure residents are competent before delegating procedures

9. Role Modeling Model professional conduct Provide support and guidance in managing conflict

10. Resident Responsibilities Residents must… Know their limits Let supervisor know if they are asked to perform tasks beyond their abilities Inform patients of their status and who the attending is Inform PD if supervision is inadequate

11. Residents must inform supervisor if… • Significant change in patient condition • Dx/management in doubt • Procedure or therapy that may cause harm is to be undertaken • Patient referred from another service • Patient is to be referred to another service • Patient is to be d/c from ER or hospital

12. Evaluation of Residents • Linked to objectives • Based on CanMEDS roles • Medical expert • Communicator • Collaborator • Health Advocate • Manager • Professional • Scholar

13. Why Evaluate Learners? Evaluation can determine… Annual promotion Examination readiness Choice of candidates for advanced training AND Can serve society

14. Evaluation and Learning Evaluation should provide direction and motivation for learning

15. In-Training Evaluation is Problematic Longstanding validity and reliability concerns with ITE Barrows (1986) • Direct observation of students limited and random • Clinical performance assessment often based on oral or written case presentation

16. Evaluation Direct observation of residents is key Credibility limited if evaluation not based on observation

17. Engagement Central to value residents place on in-training evaluations External influences on engagement Timeliness Credibility “Constructiveness” Internal influences on engagement Receptivity Reliance on self-assessment Watling et al (2008)

18. ITERs • Timely • Specific • Narrative comments valued • Constructive advice • Grounded in clinical work

19. Feedback Bing-You and Patterson (1997) Residents valued feedback that was… • Well-timed • Private • Fostered development of action plan Residents might reject feedback if sender not seen as credible • Level of respect • Content of feedback • Method of delivery

20. Feedback is Not a One-Way Street Perceptions of evaluators may differ considerably from those of trainees Sender-Liberman(2005): • 90% of surgeons felt they were “often or always” successful in providing effective feedback • 16% of residents agreed! Claridge(2003): • 61% of faculty scored their teaching abilities significantly differently from how residents scored them

21. A Shared Aversion… Teachers may avoid giving negative feedback because… • Students may be hurt • Student-teacher relationship might be damaged • Low ratings might demotivate students • Remediation might not be available (Ende 1983, Daelmans 2006)

22. Failure to Fail Dudek (2005) identified barriers to faculty failing trainees: • Lack of documentation • Lack of knowledge of what to document • Anticipation of an appeal • Lack of perceived remediation options

23. Faculty Engagement Barriers to faculty engagement in the in-training evaluation process: • Time constraints- work hours • Professionalism- impact • Handover • Limited direct observation opportunities • Inconsistency in approach to ITE • Lack of continuity between rotations • The challenge of giving negative feedback while avoiding harm to learners Watling et et al 2010, PanCanadian Consensus on RDH Sen, 2013

24. The Road Ahead Evaluation of trainees is not simple! • Complex interpersonal dynamics are involved • Characteristics, attitudes, and behaviour of participants are highly influential

25. Effective Feedback is Necessary Ende (1983) warned that a consequence of inadequate feedback during residency is that residents develop a system of self-validation that excludes evaluation from external sources Is this a problem? YES. Physicians are poor self-assessors! (Davis 2006)

26. Some Practical Suggestions Regarding Feedback Things to do… • Focus on the task • Be specific and clear • Provide elaborated feedback, but in manageable units • Facilitate a culture of feedback • Establish a trusting relationship with the learner

27. Feedback: Things to Avoid • Normative comparisons • Threats to self-esteem • Interrupting the learner with feedback if learner is actively engaged in problem-solving • Excessive use of praise • System fragmentation

28. SUMMARY Be aware Be available Be open Communicate clearly Rise to the challenge of evaluating residents constructively