Increased attending supervision may not reduce medical errors and may decrease educational outcomes

1. In this randomized controlled trial, increasing direct attending physician supervision did not reduce the rate of medical errors.

2. The increased direct attending supervision also resulted in interns speaking less during rounds and residents reporting feeling less efficient and that they had a decreased level of autonomy.

Evidence Rating Level: 2 (Good)

Study Rundown: Increased supervision from attendings in academic medical centers may improve patient safety outcomes and enhance resident learning experiences, but not many studies have investigated this question. This randomized controlled trial aimed to determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes.

There was no significant difference in medical errors with increased attending supervision. Residents spoke less when attending physicians were present for rounds and felt less efficient and felt they had less autonomy with increased supervision. Attending physicians, on the other hand, rated the quality of care higher when they participated in rounds. Strengths of this study included analysis of both medical error but also resident experience. Limitations included single-centered study, leading to reduced generalizability.

Click to read the study published in JAMA Internal Medicine

Relevant Reading: Effects of increased overnight supervision on resident education, decision‐making, and autonomy

In-Depth [randomized trial]: This cross-over design, randomized controlled trial was conducted on the general medical teaching service at Massachusetts General Hospital with 188 internal medicine residents from September 2015 to June 2016. Twenty-two faculty were randomized to provide either increased direct supervision where attendings would join rounds on previously admitted patients or provide standard supervision where attendings were available but did not attend rounds. The faculty when crossed over to the other supervision type after 2 weeks. The outcome of interest was rate of medical errors and resident education evaluated via time-motion study and surveys.

There was no significant difference in medical errors between the standard and increased supervision groups (107.6; 95% CI 85.8-133.7 vs. 91.1; 95% CI 76.9-104.0 per 1000 patient-days; p = 0.21). There was no difference in mean length of time spent discussing patients between the two models however interns spoke less when an attending joined rounds (64; 95% CI 60-68 vs. 55; 95% CI 49-60 minutes; p = 0.008). In surveys, residents felt less efficient (41 [55%] vs 68 [73%]; p = 0.02) and less autonomous (53 [72%] vs. 86 [91%]; p = 0.001) with an attending present. Attending physicians, however, rated the quality of care higher when they participated in rounds (p = 0.04).

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