Presented at Accreditation Council of Graduate Medical Education (ACGME) meeting in Nashville, TN Mar 2010. Includes overview of resident supervision, function and type of supervision in various specialties, and the SUPERB/SAFETY model of effective supervision. Includes link to video on YouTube for facilitating discussion.

1. Strategies to Improve Trainee Supervision (SES87) Jeanne M. Farnan, MD MHPE Vineet M. Arora, MD MAPP The University of Chicago Department of Medicine & Pritzker School of Medicine

6. The Case of Libby Zion, March 4, 1984 11:00pm 1:00am 3:00am 5:00am 7:00am 18 yo F presents with fever (41 o C), dehydration, and “uncontrollable shaking” Labs/studies: WBC >18K CXR clear Because of increasing agitation and uncontrolled shaking, nurses call intern several times Intern phones order for Posey jacket Libby Zion goes into cardiac arrest Haldol and cooling blanket for cont. fever Admitted to ward, given Tylenol Seen by intern and resident. Dx: “viral syndrome with hysterical symptoms” Demerol given Asch, Parker, "The Libby Zion Case. One Step Forward or Two Steps Backward?" 1988.

11. Types of Supervision Housestaff Supervision Policy, VA Consensus 2005 Type Definition Example Direct Direct contact with patient and participation in providing care alongside resident Cesarean delivery Participatory Oversight prior to or during patient care Guiding resident doing chest tube placement Indirect Review of care given by resident after the fact Post-call Internal Medicine rounds

18. What do we know about supervision? Review of literature to identify best practices & gaps

22. Supervision Studies (n=14) Specialty # of studies Clinical context Average MERSQI’s (1-18) Night-time supervision assessed Psychiatry 4 Psychotherapy & night consults 13 Yes Internal Medicine 3 Outpatient clinic, Attending rounds 11.5 No Emergency medicine 3 Enhanced attending presence in ER 12.3 No Surgery 3 Enhanced attending presence in OR 9.16 No Anesthesia 1 Intubation 12.5 No

24. Nighttime Supervision Source Design & Participants Supervision Intervention Educational Outcomes Patient Care Outcomes MERSQI Finlayson AJ et al, 1977 Pre-post study of 24 ER-psychiatric residents at AMC On-site direct attending supervision overnight of night consult residents Non-significant decrease in residents’ perception of extra pressure, isolation Increased perception of sharing the responsibility No change in learning or satisfaction 9.5

27. Understanding and improving nighttime supervision Supervision theater

28. http://www.youtube.com/user/MergeLab#p/u/3/mEsikH6PdDA

30. The University of Chicago Experience… The good, bad and ugly of nighttime supervision

31. Competing Factors Resident Attending Autonomy Hidden Curriculum Clinical expertise Billing pressures Research/clinical obligations Lack of formal supervision training Liability, Institutional culture Patient Care

41. If residents are not contacting their attending at night, how are they making decisions? Medical decision-making during uncertainty

43. The Beresford Model of Clinical Uncertainty Type Definition Case example Conceptual Do not know how to apply abstract framework to make decision Don’t know when to transfer a patient to the ICU Technical Lack knowledge regarding specific content domain or task Don’t know how to do an LP or run a code Personal Not familiar with patient or patient wishes Don’t know baseline mental status or prior course after a patient is signed over to you

45. Domain (n) Major category (n) Sub-theme (n) Technical Uncertainty (5) Procedural skills (4) Knowledge of Indications (1) Conceptual Uncertainty (11) Transitions of care (6) Escalations of Care (5) Discharge Readiness (1) Diagnostic decision-making (4) Management conflict (1) Communicative Uncertainty (2) Goals of Care (2)

46. Technical Uncertainty *Of the 4 patients identified as cases where residents expressed procedural anxiety, none received the procedure in question Major categories Representative comments Representative Patient Outcome Procedural skill (n=4) CC: Patient with HIV/AIDS, fever, and mental status changes “… just the standard work up included an LP and I felt like I couldn ’ t get, I am not trained on how to do them and I just felt like lets do this tomorrow …” Pt. treated empirically with meningitis-appropriate doses of antibiotics. Did not receive LP*

47. Conceptual Uncertainty Major categories Representative comments Patient Outcome Transitions of care (n=6) Sub-theme: Escalation of care CC: Patient with sodium of 107 “ I was really uncomfortable and nervous about it and it was one of he few times that I was so uncomfortable taking care of a patient on the floor…I ended up reassured a few hours later when clinically she was fine but probably when I think about it, if one of my interns was as uncomfortable as I was with that patient I would expect them to tell me about it and yet by the time this happened it was 1 or 2AM and I think if it had been 8PM I would have called him [my attending]…I even told him I wasn’t sure if I could call about this” Patient did not require escalation of care; patient did not suffer adverse event

48. Personal Uncertainty Major categories Representative comments Patient Outcome Goals of care (n=2) CC: Patient with severe COPD transferred from Medical ICU to Gen Medicine service “ you know I discussed with a lot, with this particular patients outpatient attending and the decision was made pretty quickly to make him comfort care and he actually died that day and I never actually talked with my attending about that patient until I talked with her later in the night and said that he had passed away and then the next day it was obvious that we had missed something on the chest x-ray…” Patient made comfort care and expired after unrecognized complication

49. Resident Management of Uncertainty: Hierarchy of Assistance “ I do “Up-to-Date” first of all and then try to get a differential and then come up with some thing ” Attending Fellows Sr. Residents Peers/Co-residents Literature

50. Resident Management of Uncertainty: Hierarchy of Assistance “ Look it up if I can’t find anything reasonable to back up something, you know if I look it up and it’s a reasonable approach, talk to my colleagues, if they have had any experience with that “ Attending Fellows Sr. Residents Peers/Co-residents Literature

51. Resident Management of Uncertainty: Hierarchy of Assistance “ I would probably say MICU is the main person that I would ask on call, the MROC is the other person” Attending Fellows Sr. Residents Peers/Co-residents Literature

52. Resident Management of Uncertainty: Hierarchy of Assistance “ Sometimes I curbside the appropriate fellow, I think I do that quite a bit, I think I do that more than talking to the attending” Attending Fellows Sr. Residents Peers/Co-residents Literature

53. Resident Management of Uncertainty: Hierarchy of Assistance “ So if I have something that is really pressing I would probably page my attending because you know he’s my boss…” Attending Fellows Sr. Residents Peers/Co-residents Literature

54. Determinants of Seeking Attending Advice Barriers (7) Facilitators (6) Conflict with autonomy (2) Existence of hierarchy (2) Fund of knowledge expectations (2) Fear of repercussion (1) Need for escalation of care (4) Options in Decision-making (1) Clinical experience (1) Attending persmission (1) “ I thought my attending was very smart but it was a pain to kind of run by things with him when he was there because it would kind of influence things too much and then you wouldn’t get a chance to make up your own mind and figure it out.” “ it wasn’t anything that critical it needed to be addressed that night, if I had been I would have been totally comfortable calling my attending because she made it a point to know that that was fine in calling”

56. Strategies to teach Supervision to Attending and Resident Physicians The SUPERB/SAFETY Model

58. Suggestions for Attendings Domain (n) Representative quote Set expectations for notification (41) “ if serious status change happens on a patient, meaning they go the unit, they die or if they clinically deteriorate, to let me know” [A] Uncertainty (68) “ I even told [my attending] I wasn’t sure if I could call, and he said definitely, call when you are unsure like this…” [R] Planned communication (36) “ on call she was to call me typically a time around 7 or 7:30pm that she would call and we would run through the people admitted ” [A]

59. Suggestions for Attendings Domain (n) Representative quote Easy availability (48) “ here’s my phone number… if you lose it, my pager is always on” [A] Reassure fears (50) “ I never felt like if I called him he is going to think I am weak, I didn’t feel that at all” [R] Balance supervision and autonomy (46) “ you don’t want to interfere with the residents' decisional and clinical judgment and decisions” [A]

60. Guides for Attending Supervision Domain (n) Sample strategy S Set expectations for notification(41) I want you to contact me if a patient is being discharged, transferred to the ICU, going to surgery or another service, dies, or leaves AMA. U Uncertainty (68) It is normal to feel uncertain about clinical decisions. Please do contact me if you feel uncertain about a specific decision. P Planned communication (36) Let’s plan on talking around 10pm on your call nights and before you leave the hospital each day. If you get busy or forget, I will contact you. E Easy availability (48) I am easy to reach by page, or you can use my cell phone or my home phone. R Reassure fears (50) Don’t worry about waking me up, or that calling is a sign of weakness, or that I will think your question is stupid. B Balance supervision and autonomy (46) Tailor for level of resident experience

61. Suggestions for Residents Domain (n) Representative quote Seek attending input early (28) “ [the residents’ trying to get better about calling sooner…when they are stuck and that’s the hardest part for them to figure out…” [A[ Active clinical decisions (39) “ you’re stretched thin….and when I actually went and saw that patient… she had already had the filter in place and I didn’t discuss it with the attending…” [R] Feel uncertain about clinical decisions (40) “ I am really on the fence and at the point would present to the attending why I think both” [R]

62. Suggestions for Residents Domain (n) Representative quote End of life care discussions (46) “ I want to be aware of major changes in status, someone is going to die, or about to die” [A] Transitions of care (43) “… and It was the decision whether or not to call the intensive care unit.” [R] Help with the system / hierarchy (22) “ there are certain things that they can’t do when dealing with attendings and such….” [A]

63. Resident Guide for Attending Input Domain (n) S Seek attending input early Involving your attending early can often prevent delays in care and provide quicker results. They are also legally responsible for patients. A Active clinical decisions Contact your attending if an active clinical decision is being made ( surgery, invasive procedure, etc.) F Feel uncertain about clinical decisions It is normal to feel uncertain about clinical decisions. You should contact your attending if you feel uncertain about a specific decision. E End of life care discussions These complex discussions can change the course of care. Families and patients should also know that the attending is aware of the discussion. T Transitions of care Transitions are risky for patients. Contact your attending if someone is being discharged, transferred to another service or ICU, or hospital. Y Help with the sYstem / hierarchy Despite your best efforts, system difficulties and the hierarchy may hinder care for patients. Attendings can help expedite care through direct attending involvement with consultants

64. How Will You Put this into Practice?

65. How do you prevent residents from rolling their eyes when you talk about supervision? Using a medical approach to this problem

67. A Differential Diagnosis for Uncertainty Type Definition Case example Strategy Conceptual Do not know how to apply abstract framework to make decision Don’t know when to transfer a patient to the ICU consider algorithm or rules Seek supervision Technical Lack knowledge regarding specific content domain or task Don’t know how to do an LP or run a code Seek supervision Consultation with experts Personal Not familiar with patient or patient wishes Don’t know baseline mental status or prior course after a patient is signed over to you Retake history Reread chart Learn during handoff

68. How do our brains make decisions in the face of uncertainty? Our brains can trick us to believe the wrong diagnosis Shortcuts General idea Definition Anchoring and adjustment bias Stick with what you were told… Tend to take the first thing you hear and label that as the diagnoses and despite contradictory information Availability heuristic Going with what it was the last time you saw a case like this… Recent diagnosis are over-weighted despite being less likely Representative heuristic If it walks like a duck… Force a diagnosis to fit based on a few symptoms despite contradictory information

69. PARIS IN THE THE SPRING

70. PARIS IN THE THE SPRING

73. Jeanne Farnan, MD, MHPE U Chicago Julie Johnson, MSPH, PhD U New South Wales, AU Holly Humphrey, MD U Chicago Emily Georgitis, MD University of Chicago Alan Schwartz, PhD UIC Ilene Harris, PhD UIC David Meltzer, MD, PhD U Chicago Shannon Martin, MD University of Chicago Lindsay Dehne-Petty, MD University of Chicago Vineet Arora, MD, MAPP U Chicago

74. Jeanne Farnan jfarnan@medicine.bsd.uchicago.edu Vineet Arora varora@uchicago.edu Questions or Ideas? For copies of our papers or tools referenced in this talk [email_address] Please visit our youtube channel: http://www.youtube.com/mergelab