Faculty supervision of anesthesiology residents providing operating room care can be quantified using an instrument published previously in Anesthesia & Analgesia.1 Supervision is a single dimensional construct that incorporates attributes including participation in perianesthesia planning, availability for help/consultation, presence during critical phases of the anesthetic, and fostering safety measures.1 The instrument incorporates 9 items (questions), each assessing a different attribute of supervision. This is not supervision as relates to US billing (e.g., Center for Medicare and Medicaid Services’ terms of “medical supervision” or “medical direction”). The instrument reliably and validly measures the quality of supervision provided to anesthesia residents according to how often (never, rarely, frequently, and always) each attribute is exercised by faculty during their clinical duties.1 There is a direct relationship between the frequency of faculty supervision and perceived quality of the supervision.1
In the current issue, De Oliveira Jr. and his colleagues2 at Northwestern University surveyed anesthesiology residents from >100 US programs. Each resident evaluated overall supervision by faculty anesthesiologists, using the 4-point scale. Because the supervision score is a mean of 9 responses, the scores are effectively continuous. Less than “frequent” supervision was associated with reported “mistakes that [had] negative consequences for the patient” with an accuracy (area under the curve) of 89% (99% confidence interval, 77%–95%). Supervision less than “frequent” also predicted “medication errors (dose or incorrect drug) in the last year” with an accuracy of 93% (99% confidence interval, 77%–98%). Although the authors measured residents’ perception of errors, because few residents were surveyed per department and evaluation was not of individual faculty, it is very unlikely that bias in perception influenced their findings.2 In our opinion, this is a landmark study with clear results: the rate of medical errors increase when faculty are less than frequently involved in resident supervision.
The authors included additional exploratory questions to interpret the findings.2 On the basis of our review of the secondary analyses, we reach the same conclusions as the authors: “anesthesiology training programs with greater clinical workloads are less able to provide adequate [i.e., frequent] perceived faculty supervision.”2
Because US residency requirements mandate that an anesthesiologist may not supervise simultaneously >2 anesthetizing locations if 1 of the rooms has an anesthesia resident as the care provider,a how can there be an association between clinical workload and faculty supervision? In another article this month, Smallman and colleagues3 counted messages to supervising faculty anesthesiologists (e.g., from an alphanumeric text paging system). Approximately half of the messages were for activity originating outside operating rooms (e.g., holding area for regional nerve block, postanesthesia care unit, and administrative issues such as billing and operating room management decisions such as moving cases).3
If anesthesiologists have frequent responsibilities outside of operating rooms, while residents are caring for patients in operating rooms, residents may perceive a lower frequency of supervisors’ tasks and behaviors than what residents consider1 optimal supervision. Consequently, we hypothesize that the following 3 potential interventions may reduce medical errors, as detected in Gildasio De Oliveira Jr. and colleagues’2 survey study.
1. Automation and communication tools that reduce interruptions of anesthesiologists for services outside of operating rooms, including systems-based practice for effective use of those tools.3 Whether such tools would enhance resident supervision and reduce medical errors is unknown.
2. Residents regularly evaluate1 individual faculty anesthesiologist’s supervision and the standard be that it is at least frequent.2 This proposal raises multiple psychometric issues, so the reliability of such evaluation is unknown. If monitoring encourages faculty anesthesiologists to maintain frequent supervision, perhaps resident errors would decline.
3. Operating room informatics tools function as virtual supervisors.4–6 For example, alphanumeric paging alerts to anesthesia providers for median BIS™ values >60 (Covidien, Mansfield, MA) or median age-adjusted minimum alveolar concentration <0.5 reduce incidences of awareness events.6 Development, effectiveness trialing, and implementation of more sophisticated alerts are important.4–7
The instrument for assessing faculty supervision is reliable and valid.1 The study by Gildasio De Oliveira Jr. and his colleagues2 shows a strong association at a departmental level between overall less than frequent supervision and residents’ medical errors. What recommendation do we have for program administrators now based on currently available scientific knowledge? Measure your residents’ perception of overall faculty supervision1 and set the expectation that the faculty overall provide a minimum of frequent supervision to residents thereby increasing patient safety.2
Dr. Franklin Dexter is the Statistical Editor and Section Editor for Economics, Education, and Policy for the Journal. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Dexter was not involved in any way with the editorial process or decision.
Name: Getúlio Rodrigues de Oliveira Filho, MD, PhD.
Contribution: This author helped write the manuscript.
Attestation: This author approved the final manuscript.
Conflicts of Interest: The author has no conflicts of interest to declare.
Name: Franklin Dexter, MD, PhD.
Contribution: This author helped write the manuscript.
Attestation: Franklin Dexter has approved the final manuscript.
Conflicts of Interest: Franklin Dexter is the coauthor of “Role of communication systems in coordinating supervising anesthesiologists’ activities outside of operating rooms.”
a ACGME Program Requirements for Graduate Medical Education in Anesthesiology. Accessed January 18, 2013. Available at: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/040_anesthesiology_f07012011.pdf. See Section II.B.2.a. Cited Here...
1. de Oliveira Filho GR, Dal Mago AJ, Garcia JH, Goldschmidt R. An instrument designed for faculty supervision evaluation by anesthesia residents and its psychometric properties. Anesth Analg. 2008;107:1316–22
2. De Oliveira GS Jr, Rahmani R, Fitzgerald PC, Chang R, McCarthy RJ. The association between frequency of self-reported medical errors and anesthesia trainee supervision: a survey of United States anesthesiology residents-in-training. Anesth Analg. 2013;116:892–97
3. Smallman B, Dexter F, Masursky D, Li F, Gorji R, George D, Epstein RH. Role of communication systems in coordinating supervising anesthesiologists’ activities outside of operating rooms. Anesth Analg. 2013;116:898–903
4. Ehrenfeld JM, Epstein RH, Bader S, Kheterpal S, Sandberg WS. Automatic notifications mediated by anesthesia information management systems reduce the frequency of prolonged gaps in blood pressure documentation. Anesth Analg. 2011;113:356–63
5. Schwann NM, Bretz KA, Eid S, Burger T, Fry D, Ackler F, Evans P, Romancheck D, Beck M, Ardire AJ, Lukens H, McLoughlin TM. Point-of-care electronic prompts: an effective means of increasing compliance, demonstrating quality, and improving outcome. Anesth Analg. 2011;113:869–76
6. Mashour GA, Shanks A, Tremper KK, Kheterpal S, Turner CR, Ramachandran SK, Picton P, Schueller C, Morris M, Vandervest JC, Lin N, Avidan MS. Prevention of intraoperative awareness with explicit recall in an unselected surgical population: a randomized comparative effectiveness trial. Anesthesiology. 2012;117:717–25
7. Epstein RH, Dexter F. Implications of resolved hypoxemia on the utility of desaturation alerts sent from an anesthesia decision support system to supervising anesthesiologists. Anesth Analg. 2012;115:929–33