Strategies for Effective On‐Call Supervision for Internal Medicine Residents: The Superb/Safety Model

Background:

Although supervision is central to resident education and patient safety, there is little to guide the use of effective supervision strategies. The aim of this study is to describe effective supervision for on‐call internal medicine residents.

Methods:

Between January and November 2006, internal medicine residents and attending physicians at a single hospital were interviewed within 1 week of their final call night of the general medicine rotation. Appreciative inquiry and critical incident technique were used to elicit perspectives on effective and suboptimal supervision practices. Transcripts were reviewed by 3 investigators and analyzed using an inductive approach to develop a coding scheme until consensus was achieved. All discrepancies were resolved via discussion until consensus was achieved.

Results :

Forty‐four of 50 attending physicians (84%) and 46 of 50 eligible residents (92%) completed an interview. Qualitative analysis revealed a bidirectional model of supervision, the SUPERB/SAFETY model. The interrater reliability calculated was 0.70. Effective supervision for attendings included: Setting expectations, Recognize uncertainty, Plan communication, Easy availability, Reassurance, Balance supervision, and Autonomy. Resident strategies for supervision included: seeking attending input early, contacting for active clinical decisions, feeling uncertain, end‐of‐life issues, transitions in care, and “you need help with systems issues.” One resident highlighted the importance of setting expectations: “It was nice to know how the team would be structured .. how our on‐call day would go, and it was very helpful to have structure to know what [the attending] expected.” Another resident explained they sought supervision when uncertain: “I can call the attendings if I have questions above my head or especially if there are options of what to do.” Attendings explained they plan communication and stressed easy availability — “1 said if you need anything give me a call; otherwise, I will plan on paging you between 9 and 10” — and their role in balancing supervision with autonomy — “because [the resident] is going to be an attending next year, and I wanted her to make some of the higher level decisions. I wanted to encourage her.” Residents appreciated the need to contact attending for active clinical decisions — “If the patient had been acutely ill, if it had been more acute, we would have called the attending” — and during transitions of care — 1 had this patient who was unstable and her mental status declined significantly, and it was the decision whether or not to call the MICU.” Finally, attendings recognize their ability to help with systems issues — “They have called a couple times because they're having difficulty with a service doing [x], and can I intervene?”

Conclusions:

Residents and attendings have explicit expectations for effective clinical supervisors. The SUPERB/SAFELY bidirectional model of supervision may be an effective guide to clinical supervision of house‐staff.

Author Disclosure:

J. Faman, AHRQ, research funding, ABIM Foundation, research funding; J. Johnson, AHRQ, research funding; D. Meltzer, AHRQ, research funding; H. Humphrey, ABIM Foundation, research funding.