Delegation and supervision of trainees

Psychologically safe learning environments must be built deliberately. Trainees’ lack of confidence in their ability and their fear of staff criticism, or even ridicule, are two major contributors to their psychological distress.¹ Supervisors – be they senior residents supervising junior residents, junior residents supervising medical students, or staff persons supervising entire teams – can create psychologically safe learning environments by actively taking steps to ease such fears. Good supervisors can promote safe medical care by learning to make trainees feel comfortable in asking any question and assuring trainees they will not be labelled as weak or incompetent for expressing concerns about their comfort level, knowledge, or skill.^{2, 3}

Open communication about a trainee’s strengths, weaknesses, skills, and comfort level with delegated tasks is the key to building a strong relationship between supervisors and trainees, promoting safe medical care and ensuring that the education provided is of the utmost benefit. Supervisors' supportive communication and willingness to help will make trainees feel comfortable voicing any concerns they have about a particular task or procedure.

Because of their varying levels of experience, confidence, and insight into their limitations and performance, trainees may not know when and how to ask for guidance. Trainees need to be empowered to ask clarifying instructions and ask supervisors for help or assistance when needed. Ideally, expectations about when to call for help should be discussed and made clear when supervisors and trainees first work together, whether at the start of a clinical shift or during a formal orientation to a clinical service.

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No person can work at optimal performance 100% of the time. Beyond this reality, trainees encounter specific challenges as they incorporate new knowledge and skills.

Trainees may:

• Have little experience in applying theory to real-life patient care.
• Feel anxiety, stress, fatigue, and self-doubt.
• Be afraid to show any weakness, or they may worry about asking for help for fear they may appear incompetent.
• Have difficulty accurately judging their level of competence in performing certain procedures.
• Over-estimate their abilities and be over-confident.
• Feel that they must conform to the pre-set personae of their medical specialty, or of their preceptor.
• Find the volume and pace of their workload incompatible with compassionate and patient-centred care.
• Be expected to supervise junior residents or medical students before they feel confident to do so.

All of these factors can compromise a trainee’s ability to make decisions, ask for help, and provide safe medical care. The use of entrustable professional activities (EPAs)⁴ can guide trainees, as well as their supervisors, in determining the trainees’ readiness to provide care and the required level of supervision.

Trainees are responsible for:

• Informing the patient of their status as medical trainees.
• Recognizing the limits of their knowledge and, as appropriate, asking for help with a patient case or procedure.
• Continuously improving their knowledge, incorporating feedback and seeking to improve their ability to manage tasks appropriate for their level of learning.
• Appropriately assessing their confidence and competence in treating the patient and any potential.
• Complications, given each patient's unique circumstances, and calling for assistance when required.
• Keeping their supervisor informed of their actions.
• Documenting their care.

To learn more about constructively voicing one's concerns, see Speaking up in Psychological safety

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The ability to effectively supervise trainees involves skills that complement those of clinical competence. Supervising physicians are teachers and mentors, guiding trainees by observing their performance, providing feedback, imparting clinical judgment, monitoring progress, determining competence, and displaying professionalism. For these reasons, trust between a supervisor and trainee is paramount.

Challenges to supervising include:

• Finding sufficient time to teach, monitor, and mentor.
• Knowing when to delegate.
• Determining the required level of supervision for a specific trainee and task.
• Supervising outside of weekday daytime hours, when the presenting cases may be of a more urgent nature and access to support resources may be limited.
• Difficulty in establishing consistent supervision and evaluation when trainees work with many supervisors.
• Failing to address underperformance.

Knowing when to delegate

In every instance of delegation, the primary consideration must be the best interest of the patient. It is also important that the medical profession recognize the collective responsibility to train the next generation of medical professionals.

Whether or not a medical act can be delegated to a trainee will depend on the treating physician's assessment of the trainee's competencies, skills, and experience. The supervising physician must exercise good clinical judgment in determining whether the trainee is clinically competent to perform a certain task. The use of entrustable professional activities (EPAs) as part of the regular assessment of trainees can be helpful in making this determination.

Over time, supervising physicians should increasingly be able to grant independence to trainees and have confidence in their ability to appropriately carry out the duties delegated to them. Similarly, by progressing through EPAs, trainees should be able to manage situations with decreasing amounts of supervision. However, having achieved an EPA does not imply that supervision is no longer required or desired. Depending on factors such as the patient's condition, the complexity of the procedure, and the level of experience and skill of the trainee, supervising physicians must determine the appropriate level of supervision on a case-by-case basis.

Considerations for supervisors:

• Do I have sufficient understanding of the clinical situation in order to delegate appropriately?
• Do I have an understanding of the plan for care and does the trainee’s role fit within that plan?
• Do I have sufficient understanding of the trainee's level of competence?
• Does the trainee know when I expect them to ask for help?
• Has the trainee demonstrated appropriate insight into their abilities?
• Am I confident that key aspects of the plan will be followed?
• Am I sufficiently accessible to provide supervision appropriate to the trainee’s needs?
• Should I be observing the delegated task or procedure?
• Have I established a psychologically safe environment for support of the trainees?

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When deciding if a task is appropriate to delegate to a trainee, it is important not to assume the individual is capable of carrying out the task based exclusively on their level of training. Rather, it is important to actively consider the knowledge, skills, and experience of the individual for the context at hand. The supervisor should then determine the degree of supervision needed, considering the following options:⁵

• Direct supervision

  Observing while being in the same room with a trainee allows for close monitoring of performance and immediate guidance. In an operating room setting, this would refer to the supervising surgeon being scrubbed in alongside the trainee. In certain contexts, direct supervision can also be conducted by video or one-way mirror.

• Immediately available supervision

  In this situation, a supervisor is not necessarily in the room with the trainee but is immediately available to come to the aid of the trainee if problems arise. In surgery for example, this would refer to a supervisor being in the OR suite but not necessarily scrubbed in for the case.

• Local supervision

  The supervisor providing local supervision is in the hospital or clinic and available at short notice.

• Distant supervision

  This type of supervision involves a trainee and supervisor not being in the same building at the same time. The supervisor is available for advice on-call and is able to come to the hospital within an appropriate timeframe.

Supervisors may sometimes make decisions about how best to supervise a trainee based on the trainee’s professional reputation, on their post-graduate training level, on how well the trainee presents a problem, as well as on the trainee's tone of voice and perceived confidence level. Such clues may not provide a fulsome portrait of a trainee’s competence. Supervisors should also demonstrate situational awareness, taking into account their own objective assessment of the trainee’s skills, knowledge, and attitudes as well as the trainee's workload and the complexity of the specific case.

It is important to keep in mind that “being signed off” on a particular EPA may not necessarily imply competence to perform that activity in an unusual context or situation. For example, a trainee who can readily intubate a patient in the operating room may not have the necessary skills to manage the airway of a patient in acute respiratory distress in the emergency department.

Considering four additional criteria can help the supervisor to determine the level of trust to place in a trainee:

1. Does the trainee know when to ask for help?
2. Will the trainee seek assistance in a timely manner?
3. Has the trainee demonstrated appropriate insight into their abilities?
4. Does this patient or situation require expertise beyond the trainee’s abilities?

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Effective communication between supervisors and trainees requires clear direction without making assumptions. For example, during overnight call, trainees may be more reluctant to reach out to their staff who may be sleeping. During the day when the staff are busy with other patients in clinic, it may also be challenging for trainees to reach out for help. To promote safe care and foster learning, supervisors should ensure that

• they make it clear to trainees that it’s always appropriate to call for help.
• they welcome calls for help when they receive them, even when sleep or work are interrupted.

Supervisors need to be cognizant of their language and the potential for implicit messaging when they communicate with trainees. Clarity of communication and a receptive attitude are essential to ensuring appropriate levels of communication and supervision, which will promote patient safety.

• Simply saying “page me if you need me” may not engender the desired level of communication.⁶
• Setting clear expectations about when trainees should contact the supervising physician is more likely to lead to safe care (e.g., for a new admission, a significant change in the clinical status of a patient, or the development of unanticipated complications).
• Encouraging trainees to reach out when they feel it is necessary and responding positively and constructively when they do call can promote the development of healthy insight.

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Addressing underperformance

Professionalism issues identified in medical training often predict future medico-legal issues when in independent practice. Supervising physicians are gatekeepers to the profession who are ethically and legally responsible for protecting patient safety. They also have a separate professional obligation to contribute to the training of future doctors. In addition to conveying knowledge and skills, supervisors must role-model professional behaviour and communication. ^{7, 8}

Sensitivity and responsiveness to the educational needs of medical trainees will enable the development of their professional attitudes and values. By being open to concerns raised by trainees, supervisors can facilitate the identification of a trainee’s individual needs. At the same time, it is important for supervising physicians to report back to Program Directors identifying any concerns with the clinical skills or professionalism of a trainee, so that such matters can be managed early and longitudinally.

The provision of faculty development for clinical supervisors can be an important key to providing safe, reliable care. Such training can help address barriers to dealing with underperforming trainees and should include how to provide effective feedback and engage in difficult conversations with learners. Institutional support, including resources and opportunities for remediation of the trainee, are also important.

Academic institutions should create a culture of collective responsibility among faculty for fostering the success of trainees. To help guide a trainee in difficulty while promoting safe care, academic leaders should enact clear guidelines or policies regarding the management of trainee performance that provide trainees with appropriate opportunities for improvement, remediation when necessary and transparent communication to enable a fair process.

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It is important that the patient perspective be kept in mind by both supervising physicians and medical trainees throughout the learning continuum. Patient care remains the primary consideration in any situation where learners are involved.

Informed consent

Informed consent is an important aspect of the provision of care and trainees must learn how to obtain it.

• The physician who performs an investigation or treatment is ultimately responsible for ensuring the patient has provided informed consent.
• Supervisors may delegate the consent discussion to trainees, but in doing so, they should be confident that the trainee has the necessary knowledge and experience to give the patient adequate explanations and answer relevant questions.
• Before they can lead a consent discussion, trainees must be familiar with the required elements of an informed consent discussion, including details relating to the investigation, procedure, or medication being prescribed, the anticipated outcome(s), material and special risks, reasonably available alternatives, and potential consequences of refusal to consent.
• If trainees are uncertain about what should be included in the consent discussion, or if a patient asks a question they cannot answer, they have a responsibility to alert their supervisor and arrange for the information to be communicated to the patient as part of completing the consent process.

Informing patients about the role of trainees

Some courts and medical regulatory authorities (Colleges) have stated that when a significant component, or all, of a medical procedure is to be performed by trainees, the patient or substitute decision-maker must be informed of this fact.

• Generally, patients should be informed of the identity of trainees who are members of the treatment team, their stage in the educational program, and their degree of involvement in the patient's care.
• When a procedure will be performed by a trainee without direct supervision, the patient must be made aware of this fact and the patient's express consent must be obtained. Express consent is explicitly granted, either verbally or in writing. The discussion, and the patient's consent, should be clearly documented in the medical record. This is a matter of particular importance in surgical settings or in situations where patients will be sedated during a procedure and thus unable to appreciate the fact that a trainee will provide all, or a significant portion of, the care without direct supervision.
• Where the trainee is expected to have a minimal role in the medical procedure, consideration should be given to what a reasonable patient would want to know, including the nature of the trainee's role within the procedure.

Patient examinations for educational purposes

A patient’s express consent is required to allow a trainee to undertake an examination exclusively for educational purposes. An examination is defined as "educational" when it is unrelated to, or unnecessary for, patient care or treatment.

An explanation of the educational purpose behind the proposed examination must be provided to the patient and express consent obtained whether or not the patient will be conscious during the examination. This consent may be given either verbally or in writing. If express consent cannot be obtained (e.g. the patient is unconscious) and there is no clinical justification for the examination, it should not be performed by the trainee.

Addressing patients' concerns about trainee involvement

Patients may have concerns about having a medical trainee directly involved in their care. Supervisors and trainees should be prepared to respond to these concerns and acknowledge the right of patients to refuse treatment by a trainee. This situation requires tactful communication.

When patients require highly specialized care in tertiary or quaternary settings, it is important for patients to understand the potential implications of their refusal given that safe and effective healthcare today is provided by teams, of which medical trainees are integral members.

In specific circumstances, it may be appropriate to explicitly inform the patient that the recommended treatment cannot be provided safely without the involvement of trainees, putting the onus on the patient to weigh the best option. Transfer of care to a non-teaching team or to another institution may be options the patient could be provided with, where possible. In these circumstances, the involvement of hospital administrators may also be helpful in determining how best to respond to patients' concerns.

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As a result of a review or disciplinary process, Colleges may identify physicians requiring remediation. When remediation occurs, a supervising physician will need to oversee their work for a required period of time, so that they may retain or regain their medical licence. Supervising physicians’ responsibilities may include observing direct care, reviewing patient records, providing guidance in various ways, and reporting to the College as needed.

The CMPA recognizes the valuable role of supervisors in the remediation process. Supervising physicians are eligible for CMPA assistance, and the CMPA can also guide members with questions about assistance and protection related to clinical supervision.

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