We can all learn from our own mistakes – in health care, the question becomes at what cost? The world has dramatically changed since the mid-1980s, when the case of Libby Zion hit the news, and gaining clinical experience could be summed up as “See one – Do one – Teach one.”

At that time, there was little resident supervision, particularly on holidays and weekends. It was also considered a badge of honor not to call on senior residents or attending physicians at night for help.

Although much has changed for the better, we continue to struggle with defining the most appropriate balance between autonomy and supervision.

Four major events have led to significant improvements in resident supervision.

First, changes to the Medicare Rule for Teaching Physicians in 1996 dictated that attending physicians must be present during the key components of any service or procedure. Second, as reported by Fromme et al., “In 2000, the Accreditation Council for Graduate Medical Education introduced a new … competency-based approach to residency education, assessment of performance became a main area of interest, and direct observation was offered as a tool to assess knowledge and skills.”

Third, the Institute of Medicine’s (IOM’s) 2008 report titled, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” made recommendations for limiting resident hours and increasing resident supervision.

Finally, in 2010, the Accreditation Council for Graduate Medical Education (ACGME) adopted common standards that provided detailed training program recommendations, particularly in regard to first-year trainees.

The new standards require that each training program include:

1. Direct supervision, which requires the physical presence of the supervising faculty member;
2. Indirect supervision, in which the supervising faculty member or a more advanced resident is immediately available in the facility to provide direct supervision, is available by phone or other electronic modality to provide direct supervision; and
3. Oversight, in which post hoc review of resident-delivered care is conducted and feedback is given to the resident regarding the appropriateness of that care.

The Council of Residency Directors has made similar recommendations recently regarding the establishment of clinical expectations for performance based on year of training.

Although changes in reimbursement and regulation play a role, they are not the only factors that have driven these improvements. Several important studies have shown increased risk to patients and liability tied to inadequate supervision. A 2004 article published in the Journal of the American Medical Association estimated that residents were named in 22 percent of malpractice claims.