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Original Investigation
June 4, 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. Published online June 4, 2018. 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.

Abstract

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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