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.
Vary Your Approach
Use a variety of formats to tell your learners what was observed. Specific, quick comments made in real time can be encouraging, and brief suggestions are usually welcome in the context of a particular patient. Other observations and feedback that need to be more sensitive or require more time are perfect to wrap up at the end of the day. Finally, the message function in the electronic medical record is another great and timely format for providing feedback on observations related to clinical documentation, differential diagnosis, and management plan.
Record your observations as you go. Even though you are providing formative feedback throughout the month, you likely also will be expected to translate those observations into a summative end-of-rotation assessment. Whether it is on a notecard with the name of each trainee being supervised or on a printed blank copy of the end of the month assessment or other program-specific assessments, jotting down specific observations will help you recall key information.
When feedback is provided, note the date in order to guide your summative feedback discussion and the final assessment.
Keep in mind that program assessment tools often serve to remind faculty of specific behaviors that have not historically been evaluated. For example, faculty might be in the habit of providing feedback on communication skills after a family meeting but may not specifically listen for trainees to use “teach-back” concepts when explaining the plan for discharge or noting whether they actively seek input from the multidisciplinary team. A tool that lists “teach-back” or “seeks out interprofessional collaboration” as line items on the form can help to remind you of the qualities you are being asked to assess.
Although direct observation is essential in providing useful assessments during the course of supervision of trainees, there are additional ways that faculty can “see” how a trainee is doing. For example, faculty or supervising residents can “observe” an intern’s completed discharge summary in real time for important and key components. Checking this work enables you to provide an assessment of additional skills (i.e., medication reconciliation, medical knowledge, management of clinical conditions, and appropriate handoff to future care providers). As trainees progressively demonstrate competence, the degree of supervision evolves to the point of a quick verification rather than the initial detailed review.
In summary, supervising trainees well means both thinking critically about their care of patients and providing feedback. As much as we have adapted our clinical workflow to meet increasing regulatory, quality, or patient throughput requirements, we must also change our educational workflow to meet the needs of our learners.
This adaptation should not be onerous. A few simple adjustments, as outlined above, can lead to higher-quality assessments and increased satisfaction in your role as teacher. So, get back out on the wards and observe!
Dr. O’Malley is the internal medicine residency program director at Banner Good Samaritan in Phoenix, Ariz., and an assistant professor of medicine at the University of Arizona College of Medicine. She currently serves as SHM’s representative on the Alliance for Academic Internal Medicine’s Internal Medicine Education Redesign Advisory Board, along with Dr. Caverzagie, who is associate dean for educational strategy at the University of Nebraska College of Medicine in Omaha and vice president for education, clinical enterprise of the Nebraska Medical Center. Dr. Caverzagie also was a member of the ABIM and ACGME milestone writing groups.