Graded Responsibility

Guidelines for Graded Responsibility in Anesthesiology Rotations

In order to meet the goals of the resident training program, residents undertake progressively greater individual responsibility for patient care over the course of their training.

The Guidelines to the Practice of Anesthesia, Revised Edition 2023 state:

" Residents in anesthesia are registered medical practitioners who participate in the provision of anesthesia services both inside and outside the operating room as part of their training. The Royal College of Physicians and Surgeons of Canada and provincial and local regulatory authorities require that a responsible attending staff anesthesiologist must supervise all resident activities. The degree of this supervision must consider the condition of each patient, the nature of the anesthetic service, and the experience and capabilities of the resident (increasing professional responsibility). At the discretion of the supervising staff anesthesiologist, residents may provide a range of anesthetic care with minimal supervision. In all cases, the supervising attending anesthesiologist must remain readily available to give advice or assist the resident with urgent or routine patient care. Whether supervision is direct or indirect, close communication between the resident and the responsible supervising staff anesthesiologist is essential for safe patient care. The anesthetic care provided by a resident must also be within the scope of practice of the supervising anesthesiologist. Each anesthesia department teaching anesthesia residents should have policies regarding the activities and supervision of residents.’’ 

Canadian Journal of Anesthesia/ Journal canadien d'anesthésie, vol. 70, no. 1 (16-55) 2023

The following guidelines outline the expectations of the faculty member and the resident regarding graded level of responsibility and supervision.

EXPECTATIONS OF PRECEPTORS:

1. Expectations of graded responsibility and resident supervision are governed by the staff anaesthesiologist's fiduciary responsibility for patient care, the provincial-residents’ agreement for health care, Surgical Patient Care Committee policy, and the educational goals (requirements of appropriate teaching and meaningful evaluation based on observed performance).

2. Finding the appropriate level of supervision is a dynamic process, often negotiated to different endpoints for each preceptor and resident assignment. Determinants are: the resident’s level of training and performance to date, resident and staff comfort levels, and the complexity of the clinical material. In all cases, the supervising staff anesthesiologist must remain readily available to assist the resident.

3. Although many of the service oriented activities of residency do enhance learning, preceptors should minimize the delegation of service tasks devoid of educational merit to trainees.

Legal considerations about delegation of care to residents require that the following questions can be answered in the affirmative:

• Is this an act that I am capable of delegating
• Is this an act that I should be delegating
• Is this appropriate to delegate this act to the resident.

With the above points in mind, the following table may be used as a guide to graded supervision of Anesthesia residents, reflecting the usual maturation of a trainee in clinical practice.

C = close supervision
I = induction / emergence / significant event
E = supervision for evaluation only

EXPECTATIONS OF RESIDENTS:

The resident who is PREPARED to accept appropriate responsibility will:

1. Have acquainted themselves with the medical, anaesthetic and surgical implications of the procedure and patient.

2. Come with pertinent identified preoperative measures and investigations that must be in place prior to proceeding. (e.g.) absence of active systemic sepsis, blood crossmatched, PFT's, creatinine, potassium level, etc.

3. Develop an anaesthetic plan including agents, procedures, and monitoring to secure a safe induction, maintenance and emergence from anaesthesia and smooth PARR course. (e.g.) Appropriate anaesthetic technique, pharmacologic choices, needs for-invasive monitoring, anticipated blood loss, patient positioning, etc.

4. Have met and discussed the above with the preceptor, acknowledged levels of supervision/technical help required and stated plans for intraoperative contingencies. Demonstrates active engagement and responsibility for the patient's anaesthetic care.

5. Will have arrived in sufficient time to prepare the anaesthetic machine and ancillary equipment for the case.

The resident UNPREPARED to receive responsibility will:

1. Come without any preparatory reading or knowledge of the case or patient problems.

2. Be unable to identify key preoperative investigations or measures. Will proceed without any thought to contraindications or measures for minimizing patient risk.

3. Have an anaesthetic plan that is "cookbook" oriented and incomplete, inappropriate or inadequate for the case. Cannot identify key intraoperative pitfalls or safe anaesthetic endpoints.

4. Be unable to participate in a meaningful discussion of the anaesthetic plan. Relies on passive learning and demonstrates no ownership for patient care. Enthusiasm limited to new anaesthetic procedures without justification of risk/benefit to patient.

5. Arrives late or allows insufficient time for anaesthetic equipment preparation.