Maintaining Supervision
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. [Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089–2094.] This deception can have profound risk management consequences. [Persson A. Letter concerning: do house officers learn from their mistakes? JAMA. 1991;266:512–513.] 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. [Bosk C. Forgive and Remember: Managing Medical Failure. Chicago: University of Chicago Press, 1979.] 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 practice.
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 and to 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 patient.