Dr. Robert Wachter, Editor, AHRQ WebM&M: As you thought about the way residents were supervised when you were a residency director, what did you think of the balance between supervision and the autonomy they had?
Dr. Lawrence Smith: My concern many years ago was that residents were undersupervised. The very good residents thrived in that situation, and the weak residents developed poor clinical behaviors because they had little or no senior input into the way they practiced and the decision-making. I'm not convinced that many patients were seriously hurt by that—because usually residents realized when they were really in over their head. Unless you had a totally malignant culture for asking for help, they usually knew when they had crossed that threshold. But the practice styles and habits that they developed often were very aberrant because they were rooted in what the person one level up from them in the training hierarchy told them, usually based on little to no evidence.
RW: What do you think of the trend of increased supervision that has developed over the past 20 years?
LS: The trend of increased supervision on its face value is not bad. The way it's often implemented defeats the principle of increasing incremental responsibility and autonomy. A resident finishing training should be observed from a pretty good distance because if you believe that the very next day they can be an autonomous practitioner in their specialty, then at some point you have to actually let them show you that they can practice autonomously. In many teaching hospitals, the hospitalist program has replaced the role of the inpatient ward attendings. As such, you take a group of physicians who are masters of patient throughput and regularizing care, often dominated by relatively young physicians who are just out of training themselves. Those people, I think, were uncomfortable supervising from afar. You know, that delicate artistic balance between you really know what is going on with the patient, but the residents believe they're out there on their own making their own decisions. So, realistically the buck stops with everybody, but you're close enough that you would catch a serious mistake. I think that experienced clinician educators get better and better at that. I think people right out of their training are the least comfortable with this supervision from afar. We've had an influx of much younger attending physicians supervising residents with a lot of mandates to be very efficient, to follow a very clear care path with many of the common admissions. As such, the result has been a group of residents who do the work but intellectually don't feel on the line and responsible for the thinking.
RW: Do you see that as just an epiphenomenon of the newness of the hospitalist movement?
LS: Not at all. I think the hospitalist movement serves a need of the hospital in terms of efficiency, patient safety, following protocols, and instituting true quality innovation. In the past, hundreds of attending physicians who only occasionally took care of inpatients were a very difficult group to ever co-opt into those efforts and have success. So, for lots of good reasons the hospitals turned to hospitalists not just for coverage but also for cultural and care model changes within the walls of their building. But the consequence for the trainees of that very same pressure on this group of physicians to do those good things was to set up a system that often didn't need the residents at all.
RW: So you see it as a fundamental part of the hospitalist mindset and job description as opposed to just the fact that the field is young at this point but may age over time and develop more seniority.
LS: I think with seniority it will probably improve some. But I think it's more the hospital creating a job description for the hospitalists that serves a set of needs that no one even thought existed 20 years ago. So I think it's the hospitals using the hospitalists as agents for other issues that have potentially threatened the full development of competency in trainees. I don't think it's the hospitalist movement that's done it but what the hospitals have asked that group of physicians to deliver for them.
RW: One way people sometimes frame this is that there's a tension between present versus future patient safety, meaning that increased supervision of the trainees may actually be improving patient safety in real time, potentially at a cost of the safety and quality of care that those same trainees deliver after they finish. Do you buy that?
LS: I think that is a delicate balance. I would argue that if what we're doing is modestly increasing patient safety concerns but really minimizing any true harm to patients. Mistakes may happen because you allow people a little bit of room in their training to be autonomous. But you have a system in place that prevents any serious harm coming from those things. I'm comfortable with that, if the end product is a much safer independent physician following the end of training.
RW: Politically and organizationally, how do you see the development of that kind of environment?
LS: I think supervision and completely substituted judgment are not the same thing. If a resident's response to every new patient is to scan a very slim history, do a modified physical exam, pick up the phone, call the attending physician, and say what do you want to do, we're unlikely to produce competent physicians at the end of that training experience. If on the other hand, we expect people to collect their own dataset, make their own judgment, order their own diagnostic tests, initiate treatment, and then say to the attending, here's what I found, here's what I started, do you agree with what I did, or are there any other things you'd like me to do, that's a very different conversation.
RW: In getting that right, is that a matter of training our faculty to pull back and to ask those questions?
LS: Yes, I think if every time the resident said, "What would you like to do?" you go, "And what do you think?" It's so much slower to say that than to just give them the answer. Especially when you just got up from the dinner table halfway through dinner, and you can terminate that phone call in 1 minute by telling them what to do or 15 minutes by asking them what they're thinking.
RW: That makes it very tricky in an environment where people are being pressed to do more work and see more patients. It may be that at their core they believe in this more hands off approach, but they simply don't feel that they have the time to pull it off.
LS: Correct. In the surgical field it probably is much more a time efficiency issue than safety. There's pretty good evidence that having a resident acting in the role of primary surgeon with an attending literally physically present doesn't increase serious mistakes or complications of surgery, but the surgery takes significantly longer. There's no argument about that. The number of minor mistakes is increased slightly, but the data also shows that the overall care of the patient with the resident team engaged in the care probably winds up better for the patient. But nobody can counter the fact that the operation takes longer and the OR becomes less efficient. That's another pressure, not safety but efficiency and cost, that puts external pressure on the system where it's just faster to permanently leave that resident as the first assistant and never as the primary surgeon.
RW: Since it may be more efficient to oversupervise and for the teacher to do more of the work themselves, with public pressures on safety that push in this direction, the question will be what the counter pressures are. Are you finding that trainees themselves are saying that we need this kind of greater autonomy in order to become effective practitioners?
LS: What I've noticed when I talk to residents themselves is rather strange. They accept whatever is the culture and the rules of the game within residency. As a result, in the surgical field what you see is that virtually no one practices surgery at the end of their core residency. Because all of them know they've not been given adequate opportunity to operate on their own, and they're really not competent to be general surgeons. The pushback comes where they really expect to be allowed to learn how to operate, which is during fellowship. They're willing to put 5 years of observe, second, and first assist work through their residency. Then they realize they're not competent primary surgeons, but they all are going to do a fellowship now. In the fellowship, they realize they have to be given that opportunity. I find it's the fellows who begin to push back if they don't get given the cases.
RW: Can you share examples of the consequences of oversupervision and the lack of independent practice?
LS: We matched a fellow in pelvic floor surgical disorders to a fellowship that's jointly run by the urology and gynecology department. This was a person graduating from a very prestigious university hospital as an OB/GYN resident who had glowing recommendations. Because the fellowship included time covering as a general gynecologist, not as a uro-gynecologist, we also put these people on staff. We gave them attending privileges for gynecology and then fellow/resident/trainee privileges to uro-gynecology. In the process of appointment, our hospital sent out the usual letters requesting verification of privileges. During verification for this resident's GYN privileges (he had completed his residency and was intending to take the boards in the next 6 months), the chairman of the department refused to sign off and sent us a letter saying, "Not a single resident has done surgery independently as the first surgeon in my program for the last 10 years because my hospital no longer believes that's safe. Therefore, there's not a single graduate in my program that I can testify can safely do surgery." And we were sitting there and everybody's looking at each other dumbfounded. So we called the chairman up and we said, "Are you giving us a subliminal message to call you? Is there a problem with this fellow?" He said, "Oh absolutely not. This was one of our best residents. I'm just telling you I'm not signing off on surgical privileges for him or anyone else who graduates from my program. None of us know if these people can actually do this surgery."
RW: I'm guessing you believe that the chairman of the department is just simply honest and that this would also be a true assessment for most of the trainees that come out of other programs.
LS: My guess was that this was a very sore spot for this man. But, he was actually being truthful to us because it was something that was a sore spot to him that this transition of training had actually taken place.
RW: And what did you do with this gynecologist?
LS: We put him under highly focused observation for the beginning, which certainly complicated the coverage scheme on our GYN service. Within short order, we discovered that he was quite competent and there were no real issues. But, I think it was important to understand that this training program watching him for 4 years had made no determination of whether he was a safe surgeon.
RW: Is that because they are responding to public and accreditation pressures?
LS: That was the implication of the conversation.
RW: Do you think the training program directors have the freedom now to get this balance right?
LS: I'm not sure. I would have said experienced program directors with supportive department chairs can clearly do it. Because I think that a dozen years ago, even in the face of the rising concern over safety and quality, I was able to do that. I'm not sure that's true anymore.
RW: I sense that you worry more about procedural competency than cognitive competency?
LS: I do.
RW: What should certifying boards be doing in an environment where it's their job to certify that people are competent at the end of their training? How do the boards need to approach this in a different way?
LS: I think the literature is pretty clear that a resident or a fellow in surgery, doing even a difficult case with the senior attending standing there, really does not present a risk to the patient or present a time issue to the OR. The surgical Residency Review Committees have rules that say that the surgical chief resident must be the primary surgeon when they're asked to scrub on a case, and this is clearly completely ignored in many, if not all, surgical programs right now. So there must be a tacit non-enforcement of this rule.
RW: So you see it as one of the roles of the boards to produce counter pressure to ensure that people are competent at the end of their training?
LS: Right. Especially for procedures because I don't think the issue is really safety. When someone is standing there with their hands ready. I really think the issue is time.
RW: You are now the founding dean of a medical school, and you have some power to create a culture and an environment that appropriately balances training, efficiency, and safety. How does your school look different than others as you had a chance to put your imprint on this?
LS: We have certainly focused on the fact that medicine is a skillset, even the cognitive fields of medicine are skills. It's not just knowing things. We've focused on knowledge in action and being able to take that knowledge to effectively care for patients. It's a paradigm that we've spun the whole curriculum around. We've also invested heavily in simulation, hoping that what makes people hesitant to let a trainee do something for the first time, we can do with either simulation or skills laboratories to give the supervising physicians a level of comfort that these trainees have had enough practice in a no-risk situation that they're ready to do it in the real situation.
RW: How do you respond to the patient who comes in and says, "I really don't want trainees mucking around with me and learning from their mistakes?"
LS: On an individual basis that has to be the patient's right. I'm not going to sit there and fight with a patient. On the other hand, as a society we have to recognize that if we don't train the next generation of physicians, we're going to create an awful mess for ourselves in relatively short order. We have to realize that we're asking people to take a system that has had very little respect for safety and few true measures of quality and now trying to make up enormous ground compared with other industries. At the same time, we cannot lose sight of the fact that there's still a mandate to produce competent physicians of the future. And there may be a conflict between those two goals. It's unlikely to be a large conflict, but it's also unlikely to be zero. And how do we strike that appropriate balance?
RW: We posted a recent article on AHRQ Patient Safety Network that suggested longer training might be needed. How do you respond to that?
LS: I don't think that's the answer. I don't think longer training has anything to do with the fact that if at some point you don't feel like the buck stops with you, you don't make that transition into a competent independent practitioner.
RW: What do you think this issue will look like 5 or 10 years from now?
LS: I think it's only going to get more difficult, especially in the procedural fields. The minimally invasive and robotic technologies make so much of this surgery almost a single operator procedure now instead of a team truly doing a coordinated symphony of work on the patient, so it becomes an ever increasing big deal to hand over the robotic controls to someone else. It's different than trading the retractor for the scissors. The technology is racing ahead. If we don't tackle this now, it's only going to get more difficult. I also think that the interplay between using the hospital only for procedures and critically ill patients, while all the real thinking, judgment, and decision-making takes place before and after the hospital is stressing the educational technology of residency training, because the residents are not necessarily in the right place to learn critical thinking in their field. We have to take a step back and say, "How do we not thwart all the advances we've made in patient safety and still be capable of training competent physicians?" I actually believe that if we took that on as a mandate we would come up with a safe hospital and still be training competent doctors.