All of us who work with housestaff understand that a crucial component of teaching clinical medicine is to take the time to both supervise resident work and deliver constructive feedback on its quality. In the assessment of competence, trainees have “direct supervision” when an attending, senior resident, or other individual is physically present and guiding the care in real time or “indirect supervision” when work is being checked after the care has been administered.
Regardless of the level of supervision, checking in with direct observations (watching trainees do the actual work in real time) provides invaluable information for both patient care and resident assessment. Given that assessment and supervision are key components of the Accreditation Council for Graduate Medical Education’s (ACGME) Next Accreditation System, many programs are now placing particular emphasis on the time we spend observing our trainees.
How can faculty fit direct observation into an already busy day? Here are some ideas for how to adapt and leverage your workflow to create new opportunities for resident skills assessment.
Gone are the days of sitting in a patient room for an hour observing a long history and physical performed by the resident or student that you are supervising. In spite of time constraints, you should aim to be at the bedside at the same time as the trainee as much as possible. Once there, take note of all that you see. For example, we often observe residents and students during bedside rounds or critical family discussions. Here are additional opportunities for trainee observation that might fit into your workflow:
- First thing in the morning, when the team is pre-rounding (this is perfect for when you are worried about a patient or are scheduled for a busy afternoon). Do NOT interrupt the resident workflow. Instruct them at the beginning of the rotation that you plan to observe unannounced. If they see you, they should continue with their normal activities. Pop in and out to catch key points, and gather the information necessary to guide patient care. Don’t take over to do teaching or feedback; that will come later in the day.
- During a procedure performed by a supervising resident who already has demonstrated technical competence. Bring a computer on wheels into the patient’s room, sit down, and catch up on charting while listening to and observing the explanations, teaching, and interaction between the patient and the resident. You can still intervene if necessary, but take appropriate steps to allow resident autonomy and the observation of high-level communication skills.
- At the bedside of a clinically unstable patient. If you are together with the team when a nurse calls with a concern, you can instruct the resident to go ahead and intervene with close follow-up in a few minutes. This allows residents to get a head start, gather information, and establish themselves as the decision-makers, while still providing an opportunity for close observation by the faculty.
- Finalizing a discharge first thing in the morning. With most hospitals focusing on discharge timeliness, faculty often discuss patients scheduled for discharge prior to or outside of formal rounds. Get to the patient! Observe the resident interacting with the patient and multidisciplinary team, confirming medication reconciliation, finalizing the discharge diagnosis and instructions, and inquiring further about barriers to adherence with the discharge regimen.