1. Supervising Residents Chris Watling MD, MMEd, FRCPC Associate Dean Postgraduate Medical Education

2. Principles 1. Residents need hands-on experience 2. Residents and supervisors must act in the best interests of the patient 3. Every patient must have a medical staff person ultimately responsible for his or her care

3. The learning environment  Must be SAFE  For residents  For patients  Should FACILITATE residents acquiring knowledge and skills set out in their objectives

4. Delegating Tasks  Impractical for supervisors to oversee every decision and action made by residents BUT…  Ensure residents are only given tasks within their competence

5. Delegation  Can delegate some supervisory tasks to senior residents BUT  Cannot delegate the ultimate responsibility for the patient as MRP

6. Be Aware Of…  Learning objectives  Resident’s skill/training level  Residents with difficulty identifying their limitations  Residents unable to provide safe care because of  Stress  Fatigue  Patient overload

7. Supervisory Responsibilities  Ensure patients are informed of trainees’ status  BE AVAILABLE when urgent judgment is required  Respond to pages  Return to hospital if needed  Ensure, with colleagues, a call schedule that provides residents with 24/7 supervision

8. Supervisory Responsibilities  Confirm admission documentation within 24 hours  Review acutely ill patients at least daily  Orient residents to their roles and responsibilities  Ensure residents are competent before delegating procedures

9. Role Modeling  Model professional conduct  Provide support and guidance in managing conflict

10. Resident Responsibilities Residents must  Know their limits  Let supervisor know if they are asked to perform tasks beyond their abilities  Inform patients of their status and who the attending is  Inform PD if supervision is inadequate

11. Residents must inform supervisor if…  Significant change in patient condition  Dx/management in doubt  Procedure or therapy that may cause harm is to be undertaken  Patient referred from another service  Patient is to be referred to another service  Patient is to be d/c from ER or hospital

12. Evaluation of Residents  Linked to objectives  Based on CanMEDS roles  Medical expert  Communicator  Collaborator  Health Advocate  Manager  Professional  Scholar

13. Why Evaluate Learners? Evaluation can determine…  Annual promotion  Examination readiness  Choice of candidates for advanced training AND  Can serve society

14. Evaluation and Learning  Evaluation should provide direction and motivation for learning

15. In-Training Evaluation is Problematic  Longstanding validity and reliability concerns with ITE  Barrows (1986)  Direct observation of students limited and random  Clinical performance assessment often based on oral or written case presentation

16. Evaluation  Direct observation of residents is key  Credibility limited if evaluation not based on observation

17. Engagement (Watling et al, 2008)  Central to value residents place on in- training evaluations  External influences on engagement  Timeliness  Credibility  “Constructiveness”  Internal influences on engagement  Receptivity  Reliance on self-assessment

18. ITERs  Timely  Specific  Narrative comments valued  Constructive advice  Grounded in clinical work

19. Feedback Bing-You and Patterson (1997)  Residents valued feedback that was…  Well-timed  Private  Fostered development of action plan  Residents might reject feedback if sender not seen as credible  Level of respect  Content of feedback  Method of delivery

20. Feedback is Not a One-Way Street  Perceptions of evaluators may differ considerably from those of trainees  Sender-Liberman (2005):  90% of surgeons felt they were “often or always” successful in providing effective feedback  16% of residents agreed!  Claridge (2003):  61% of faculty scored their teaching abilities significantly differently from how residents scored them

21. A Shared Aversion…  Teachers may avoid giving negative feedback because…  Students may be hurt  Student-teacher relationship might be damaged  Low ratings might demotivate students  Remediation might not be available (Ende 1983, Daelmans 2006)

22. Failure to Fail Dudek (2005) identified barriers to faculty failing trainees:  Lack of documentation  Lack of knowledge of what to document  Anticipation of an appeal  Lack of perceived remediation options

23. Faculty Engagement (Watling, 2010) Barriers to faculty engagement in the in- training evaluation process:  Time constraints  Limited direct observation opportunities  Inconsistency in approach to ITE  Lack of continuity between rotations  The challenge of giving negative feedback while avoiding harm to learners

24. The Road Ahead Evaluation of trainees is not simple!  Complex interpersonal dynamics are involved  Characteristics, attitudes, and behaviour of participants are highly influential

25. Effective Feedback is Necessary  Ende (1983) warned that a consequence of inadequate feedback during residency is that residents develop a system of self- validation that excludes evaluation from external sources Is this a problem? YES. Physicians are poor self-assessors! (Davis 2006)

26. Some Practical Suggestions Regarding Feedback Things to do… Focus on the task Be specific and clear Provide elaborated feedback, but in manageable units Facilitate a culture of feedback Establish a trusting relationship with the learner

27. Feedback: Things to Avoid  Normative comparisons  Threats to self-esteem  Interrupting the learner with feedback if learner is actively engaged in problem- solving  Excessive use of praise  System fragmentation

28. SUMMARY  Be aware  Be available  Be open  Communicate clearly  Rise top the challenge of evaluating residents constructively