These factors must be weighed against the level of oversight necessary to ensure patient safety. Many institutions have adopted a graded level of supervision based on the experience of the resident, observed clinical competency, and the complexity of the case.

No clear answer is suited for all circumstances. However, below are some common strategies that attempt to strike the right balance.

• Younger physicians generally require more supervision earlier in their careers.
• More complex patients or procedures may require a greater level of direct supervision.
• Asking for help early in a case is often better than delaying a request for help.
• Increased communication should be encouraged, and supervising faculty should set expectations that address any resident concerns or fears about appearing unintelligent or weak or complaining of fatigue.
• Residents should adopt a team approach on three fronts: (1) all residents should feel empowered to speak up; (2) all residents should be included in discussions; and (3) reporting errors, adverse events, and near misses should be encouraged.
• Consider adopting “triggers” that mandate communication with attending physicians, such as a change in clinical status, patient transfer to another facility, and sentinel events, such as cardiac arrest or transfer to the intensive care unit.
• Using regularly scheduled times to contact faculty can enhance communication.
• Programs should comply with current hospital bylaws and ACGME requirements.
• Residents should be involved in both claims and patient safety programs.
• Inform residents of pertinent hospital policies and guidelines, such as HIPAA regulations, clinical guidelines, moonlighting malpractice coverage, and transfer protocols.
• Consider developing tiered responses that are based on the complexity of the patient and/or procedure.
• Structured handoff processes, such as emergency department rounding with the team, can decrease communication errors.

Much can still be done to mitigate risk by ensuring appropriate and adequate supervision for physicians in training. The fundamentals of a good risk strategy are based on open communication, handoffs, scope of practice, transparency, and documentation.

Dr. Billingham is an emergency physician and Chief Medical Officer for Medical Protective Insurance Company and is Emeritus Chair of the Emergency Medicine Patient Safety Foundation. Dr. Gelb is a professor of emergency medicine at the University of California, San Francisco and is chair of the UCSF Risk Management Committee at San Francisco General Hospital.