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Original Investigation
July 2018

Effect of Increased Inpatient Attending Physician Supervision on Medical Errors, Patient Safety, and Resident EducationA Randomized Clinical Trial

Author Affiliations
  • 1Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
  • 2Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
  • 3Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Intern Med. 2018;178(7):952-959. doi:10.1001/jamainternmed.2018.1244
Key Points

Question  What is the effect of increased attending physician supervision on a resident inpatient team for both patient safety and educational outcomes?

Findings  In this randomized clinical trial of 22 attending physicians each providing 2 different levels of supervision, increased supervision did not significantly reduce the rate of medical errors but did result in interns speaking less and residents reporting a decreased level of autonomy.

Meaning  Residency training programs should have more flexibility in balancing patient safety, resident autonomy, and learner needs.


Importance  While the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety.

Objective  To determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes.

Design, Setting, and Participants  This 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program.

Interventions  Twenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order.

Main Outcomes and Measures  The primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings.

Results  Of the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04).

Conclusions and Relevance  Increased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.

Trial Registration  ClinicalTrials.gov Identifier: NCT03318198

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    2 Comments for this article
    Broadening our Perspective on the Study of Attending Physician Supervissory Practices
    Mark Goldszmidt, MD, PhD, FRCPC | Schulich School of Medicine & Dentistry, University of Western Ontario
    To begin with, I would like to congratulate the authors on the completion of a complex and challenging study. The scope of the task taken on with this study was truly remarkable. While, as the associated editorial commented, it is possible that their findings may have been different in a different setting and with different measures of error and that perhaps a different design would have yielded more definitive results, I would suggest that there is another perspective that we should consider. Moreover, I would suggest that this perspective represents one of the challenges to studying social phenomena using randomized trial based designs .

    In particular, I am interested in practice variability and in the things that were perhaps not measured/observed for and their implications for this type of research. While all of the participating attendings may have been considered good clinical teachers by the residents that they supervise, this does not mean that they supervise in the same way. I would go so far as to suggest that it is highly unlikely that they do. In a recent study that I was involved in, building on Kennedy et. al. 2007 work on frontstage and backstage supervision, we identified four different approaches attendings took to clinical supervision (Goldszmidt et. al. 2015).
    While I can imagine all four approaches being used by attendings in the study, I am quite certain that even when carrying out the same tasks (e.g. rounding with the team) they would have enacted them very differently. For example, as Kennedy has also pointed out, not being physically present does not mean that the attending is not actively supervising. Most attendings have backstage practices -things the residents do not see them doing - that help them to ensure patient safety. They do not however all share the same practices. Some have very elaborate practices and others are more easy going. While I could elaborate further, the point I am making is that it is very difficult to be sure that the phenomena of study - rounding with or not - can be studied with a randomized trial design.
    I also suggested that other important characteristics could have been observed for or measured that would have greatly enhanced the study findings. One example would have been outliers. Were there attendings, regardless of which style of rounding that they used , who stood out in relation to their colleagues? If so, what did they do differently? While I was impressed with the time-motion observations it left me wondering if the observers could have explored other important differences reflective of attending style. These could have included descriptions of what the discussions focused on, the degree to which attendings differed in their ability to engage the team, think reflexively, role model patient centeredness etc.
    In a world increasingly asking for meaningful, measurable patient care relevant outcomes of education, I would suggest that this study provides, once again, a great demonstration of why, even when designed well, this may be an insurmountable task. At the minimum, I would suggest that it argues for the need to educate key stakeholders about the importance of asking different questions and exploring rich description over statistically significant differences.
    The Value Of Studies
    Domenic Esposito, M.D. | Università Politecnica Delle Marche
    Findings were interesting but not unexpected. Simply participating in a study results in better patient care( in this case less errors). It’s one of the real values of an academic setting.