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