A staff physician should never turn over care of the patients on the service to
an unsupervised resident. If the staff physician is unavailable to supervise
the service, another equally qualified physician must assume this
responsibility. Although residents and fellows may have independent licenses to
practice medicine, they are viewed as students and therefore not appropriate
substitutes for their teachers.
A physician who undertakes the education of students, whether in private
practice or in the school, has a fundamental duty to supervise their
activities. The most important part of this supervision is making sure that the
student does not harm the patients or interfere with the physician-patient
relationship. As a recent study illustrates, this is complicated by the
tendency of residents to hide their mistakes from their attending physicians,
as well as their patients. This deception
can have profound risk management consequences. The students must understand the importance of reporting
all problems to the attending physician. It must be clear that it is expected
that students make mistakes. It is
covering up a mistake that is unacceptable. The physician also must ensure that
the student does not violate the law or go beyond the allowable scope of
Preventing harm to the patients requires close supervision of everything the
student does to or for a patient. It is acceptable to have a student write
orders if the nursing staff knows that the orders are only advisory and cannot
be acted upon until reviewed and approved by the attending physician. If it is
not possible to ensure that student orders will not be acted on, as is the case
in most private hospitals, students should not write orders in the patient's
chart. If a student is going to do a procedure on a patient, the attending
physician should personally assist the student to prevent wrong actions or take
over the procedure if the student has difficulty.
Maintaining the integrity of the physician-patient relationship is important to
successful teaching within a private practice. Patients may choose whether they
wish to participate in the teaching program. The student should understand that
he or she must be as unobtrusive as possible. If the patient is uncomfortable
with the situation, then compliance is likely to suffer and the quality of care
will deteriorate. The attending physician's first duty is always to the
Wu AW; Folkman S; McPhee SJ; Lo B: Do
house officers learn from their mistakes? JAMA 1991; 265:2089-94.
Persson A: Letter concerning: Do house officers learn from their mistakes?
JAMA 1991; 266:512-13.
Puckett AC Jr; Graham DG; Pounds LA; Nash FT: The Duke University program
for integrating ethics and human values into medical education. Acad Med 1989
Bosk C: Forgive and Remember: Managing
Medical Failure. 1979.