To the Editor:
Dr. Sklar’s1 April editorial calls for more opportunities for experienced clinical faculty to observe trainees without interruption from other patient care responsibilities. Although we admire this vision for resident education, we note the difficulty of attending to required teaching duties in the current culture of academic health centers (AHCs), where patient care is an important source of revenue and where it is unclear how Accreditation Council for Graduate Medical Education guidelines for first-year resident supervision are enforced.
Without appropriate observation it is difficult if not impossible to determine if and when residents have achieved entrustable professional activities around a specific milestone.2 In a recent study, we found that residents were observed 70% of the time in their second month of training.3 On evening and weekend shifts, senior residents and nurses were much more likely than faculty to observe resident performance.
So, how do we meet this daunting responsibility of observing residents and making certain they achieve the necessary milestones? We suggest the following:
* Require faculty development around microskills that enable faculty to be more prepared to balance patient care and educational responsibilities.4
* Pay key faculty who are invested in education to be responsible for most of these observations.
* Train senior residents and nurses for what we want them to observe in junior residents and how to report observations electronically to a central repository.
* Engage residents in the development of benchmarks for residents to use as self-assessment tools for generic milestones that cross departmental lines (e.g., communication skills).
We can create “important moments of magic” as Dr. Sklar1 suggests, and we can be more accountable to all of the stakeholders involved in resident education, most importantly to patients. But we are not certain these moments will occur on a regular basis without changes in the culture of AHCs.
Larrie Greenberg, MD
Senior consultant for medical education and clinical professor of pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC; Lgreenbe@gwu.edu.
Third-year medical student, George Washington University School of Medicine and Health Sciences, Washington, DC.
Jennifer Keller, MD
Residency program training director and associate professor of obstetrics–gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC.
Benjamin Blatt, MD
Director, Clinical Learning and Skills Simulation (CLASS) Center, and professor of medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
1. Sklar DP. Faculty supervision of residents—creating important moments of magic. Acad Med. 2013;88:431–433
2. Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85:1408–1417
3. Tully K, Keller J, Blatt B, Greenberg LA. Time-motion study on residents early in training: Are they observed, do they receive quality feedback and does time of shift matter? Poster presented at: Pediatric Academic Societies Annual Meeting; May 2013 Washington, DC
4. Wilkerson L, Sarkin RT. Arrows in the quiver: Evaluation of a workshop on ambulatory teaching. Acad Med. 1998;73(10 suppl):S67–S69