Medical trainees require hands-on experience, and practising physicians are called upon to assist in their training. Teaching physicians have a unique and important dual role: to ensure patients receive optimal care, and to provide meaningful learning opportunities for their trainees.
Liability risks for supervising physicians stem from this dual role. It is important to understand both responsibilities in delivering patient care and what tasks can be delegated to the trainees under their supervision.
Supervision of trainees
While medical students observe and contribute to the work of a practising physician, residents carry more responsibility in patient care. Supervising physicians can reasonably rely upon residents to carry out the duties properly delegated to them; however, they must be aware of circumstances when more active supervision is required. This will depend on such factors as the patient's condition, the complexity of the procedure, and the level of experience and skill of the resident. Physicians supervising international medical graduates (IMGs) who are new to practice in Canada through other pathways will also want to be familiar with any practice restrictions that may be imposed on IMGs by their provincial or territorial medical regulatory authority (College).
Supervising physicians may also be called upon to oversee the training of other healthcare providers such as paramedics or physician assistants. Supervising physicians may be less familiar with the training and skill of such providers, so it will be important for those physicians to inform themselves accordingly. The supervising physician must determine what the appropriate level of supervision should be given the level of training and skill of the trainee. The physician should also confirm that the trainee has adequate professional liability protection.
Supervising physicians may also delegate some of a medical student's training or supervision to a resident. This should only occur if the physician deems it appropriate, taking into account the requirements of the training program, the skill and training of the resident, the tasks to be performed by the medical student, and patient safety considerations.
Delegation should only occur in appropriate circumstances. In every instance of delegation, the primary consideration must be the best interests of the patient. Whether or not an act can be delegated will be dependent on the physician's assessment of the trainee's competencies, skills, and experience. Assessing whether a trainee is adequately trained can be difficult. The physician must exercise good clinical judgment in determining whether the trainee is clinically competent to perform the chosen task.
Failing to adequately supervise a medical trainee or the inappropriate delegation of tasks could result in liability for the supervising physician for harm caused to a patient as a result of a trainee's actions. If a case finds its way to court, the court will evaluate whether the supervising physician met the standard of care when delegating the task to the trainee. A court may be critical of a physician who delegates tasks to a trainee that are beyond the individual's training and experience. The court usually considers the degree of care and skill that might reasonably have been applied by a supervising physician in similar circumstances. This involves establishing the prevailing and approved practice, as well as any changes or advancements in treatment techniques and technology.
Residents are subject to the same standard of care as other residents with the same training and qualifications. In determining the standard of care, the court will consider the opinions of experts in the related field of medicine and look to standards adopted by medical specialty organizations.
Obtaining patient consent
Informed patient consent must be obtained prior to providing non-urgent treatment. Supervising physicians and medical trainees will want to clarify who is responsible for obtaining consent. The task of obtaining consent may be delegated to residents if they have the experience and skill to provide the patient with the information necessary to the discussion on informed consent.
Supervising physicians should consider the circumstances in which trainees should be identified and patients informed of a trainee's involvement — and the extent of that involvement — in their care. The discussion and the patient's consent should be documented in the medical record.
Standard of care
Supervising physicians will want to be familiar with the standard of care to which particular trainees can be held. Supervising physicians should encourage trainees to recognize their own limitations and work within them. Residents should not undertake tasks that are beyond their training and experience.
The risk of an adverse clinical outcome can be minimized when supervising physicians and residents communicate effectively concerning the delivery of patient care. Protocols could also be instituted to, for example, assist trainees in determining when guidance should be sought from the supervising physician.
In the event of litigation, the supervising physician will be held to a standard of care that could reasonably be expected of a prudent physician in the circumstances. The trainee will be held to a standard of care appropriate to the situation and to his or her level of training and experience. In addition, the supervising physician could be held liable for any harm caused by a trainee's negligence if the physician inappropriately delegated the task or did not properly supervise the trainee during the task.
Educational obligations
Physicians have a professional obligation to contribute to the training of future doctors. However, teaching skills are not necessarily natural and must often be learned. Styles of teaching can vary by individual as well as by culture.
Supervising trainees and carrying out formal appraisals of their progress can sometimes be complicated by issues related to communication and misunderstandings. Such issues can lead to disputes or complaints.
Sensitivity and responsiveness to the educational needs of trainees will enable the development of a student's professional attitudes and values. Being open to concerns raised by trainees can support clear communication.
It is important for physician-teachers to report back to academic programs by promptly returning assessments as well as by providing timely identification of any concerns related to professionalism.
Meanwhile, if disputes or complaints do arise, the supervising physician could become the subject of an academic complaint to the training program director or to a human rights commission if discrimination is alleged. The supervising physician should contact the program director or the CMPA for advice in those circumstances.
Guidelines and policies
Supervising physicians and trainees should be aware of policies and guidelines issued by the relevant College regarding delegation to, and supervision of, trainees.
Physician supervisors are generally eligible for CMPA assistance should they encounter medico-legal difficulties when supervising medical trainees or other providers.
Key points
- Hospital guidelines and protocols, and College policies and guidelines on delegation and supervision, should be familiar to supervising physicians and trainees.
- Supervising physicians should be satisfied that trainees have adequate liability protection.
- Failure to adequately supervise trainees could result in medico-legal difficulties for supervising physicians.
- The extent to which tasks should be delegated to a trainee and the appropriate level of supervision will depend, in part, on the trainee's level of training, skill, and experience, and should take into consideration the task involved and the clinical situation. Supervising physicians should be appropriately hands on and see the patient with the trainee, when necessary.
- Trainees should be properly oriented by supervising physicians on the situations in which trainees should contact a supervisor about a patient.
The CMPA website has additional information useful to both supervising physicians and medical trainees. Of particular note is the “Physician-team: Delegation and supervision of trainees”, CMPA Good practices.
Members needing advice or additional information regarding their role and responsibilities when teaching and supervising trainees should not hesitate to call the CMPA and speak with a physician advisor.
Considerations discussed in this article also apply in Québec, where a regulation allows trainees to carry out reserved acts assigned to them under the supervision of a physician.
