The College of Physicians and Surgeons of Ontario
Supervision of Post-Graduate Trainees
Reciprocal and Complementary Obligations Between the Responsible Physician and the Trainee
In order to successfully train doctors for future unsupervised practice, medical training programs must include active participation of post-graduate clinical trainees in the provision of health care, through hands-on experience in a system of delegated and graded responsibility.
It is understood, however, that such training must be undertaken with adequate supervision. It is suggested that supervisors confirm their malpractice coverage, especially if the trainee is not associated with an Ontario university program.
The College has developed the following "Statement of Principles and Guidelines Regarding Supervision of Post-graduate Clinical Trainees" to assist teaching centres and physician practices in defining the type, degree, quality and adequacy of supervision.
Supervision of postgraduate clinical trainees may be defined as the guidance, observation and assessment of the professional activities of a trainee by the responsible physician in respect to the diagnosis and treatment requirements of his or her patients, in keeping with the educational objectives of a particular training program. The type, degree, quality and adequacy of supervision that has been established by custom cannot be readily defined by specific criteria but is based upon general principles and guidelines.
The College recognizes that for a program to be successful in training doctors for future unsupervised practice, these postgraduate clinical trainees must actively participate in the provision of health care, i.e., have hands-on experience, in a system of delegated and graded responsibility. By not only observing, but doing, the trainee learns how to question, examine, diagnose, treat and follow, and master the necessary professional attitudes towards patients and their relatives, colleagues and other members of the health care team. These are the elements of clinical competence and can only be acquired in a real life setting where education and service complement each other.
The College believes that the public is well served through the interaction of medical education and service. To further the public trust and interest, the College emphasizes the following aspects of supervision in the clinical education system to ensure the continuing attainment of exemplary standards.
The type and level of professional relationship in respect to supervision should be dictated by internal policies as determined by the training program and the hospital.
Teaching services (inpatient, ambulatory clinics, emergency, diagnostic services) and practices are required to define and have teaching staff and postgraduate trainees aware of requirements concerning supervision and delegation of responsibilities that may be more specific to a particular service, discipline or practice.
1. The Degree of Supervision Required
The degree of supervision is determined by three components:
(a) The Responsible Physician
The degree of supervision of a trainee places a finely balanced weight of responsibility on the clinical teacher as the patient's attending physician. This is a balance between personal responsibility for the nature and quality of patient care, and the established process of delegation of appropriate responsibility for patient care to a trainee for educational purposes. These dual responsibilities are complementary in optimizing the quality of patient care as well as providing the vehicle for trainee evaluation.
Ongoing evaluation of trainee competence should be documented at regular intervals, to ensure feedback to the trainee as part of the educational process, and to substantiate the basis for delegating levels of responsibility. This assessment includes direct observation of the trainee's clinical and communicative skills. The results of these assessments are used, in part, in the process of awarding licensure and certification of competence.
(b) The Trainee
Postgraduate clinical trainees, although they may have a diverse background of medical education, have met the College's requirements to enter supervised postgraduate training. Their experience and clinical competence varies from those undergoing preregistration training to residents in senior levels of specially programs.
Regardless of level of training or competency, postgraduate trainees are not independent practitioners, nor are they specialists. They are pursuing their individual objectives towards independence, in a graded fashion, providing health care services under the appropriate supervision of their assigned clinical teachers in a particular training program. The goal of every program is to bring all trainees to the point where they can act independently in their area of demonstrated competence. This ability to function independently does not come suddenly at the end of training, but is a progressive and selective process. The degree of independence and the type of service rendered independently corresponds to the level of training and the progress of the trainee.
(c) Reciprocal and Complementary Obligations Between the Responsible Physician and the Trainee
The trainee and the clinical teacher have reciprocal and complementary obligations. The responsibility of the clinical teacher is to supervise the trainee and to permit independent practice and decision making to the trainee only to an extent that is justified by the competence and experience of the trainee. The trainee has an obligation to report to the clinical teacher sufficient information as to the case at hand and as to their experience and training so that a reasonable clinical teacher could make a proper decision about appropriate delegation of clinical authority. The clinical teacher should not require independent exercise of judgment from the trainee which is beyond the trainee's knowledge. There shall be a mechanism in place to resolve disagreements between the trainee and the supervisor concerning, but not limited to, patient care (including diagnosis and delegation of procedures or other investigations) and management. The mechanism shall provide for urgent intervention or action when required for care of a patient.
2. Exchange of Information
Adequate supervision is dependent upon an ongoing exchange of information. Thus the trainee, by accepting responsibility from the supervisor, must accept the responsibility of documenting and keeping the supervisor informed of their actions.
(a) Principles of Notification
The following principles of notification of the responsible physician by clinical trainees are not rigid rules, but are intended as a general outline to supplement current custom, recognizing variations between disciplines and services.
- The responsible physician is to be notified of any patient admitted to hospital under elective or emergency situations. The name of the responsible physician should be given by the trainee or other health professional to the patient and relatives during the admission.
- The responsible physician, is to be informed of any significant change in the patient's condition; whenever an unusual or unexpected finding is observed; whenever the diagnosis or management is in doubt; prior to the undertaking of a procedure or therapy which has the potential for immediate or future serious morbidity.
- The responsible physician should be notified prior to a patient's discharge from an emergency department, ambulatory setting, or hospital inpatient service unless such discharge has been previously approved either for that particular patient or for a category of patients for which the trainee has demonstrated competence.
- The responsible physician should be notified of requests by the patient and/or relatives.
- It is recognized that in certain emergency situations, prior notification may not be possible.
(b) Type of Notification
In order to prevent or minimize any potential problems, the notification should be documented in the patient chart by the trainee or other appropriate health professional.
Recorded validation, within a reasonable time, by the supervising attending physician of pertinent aspects of each patient's history and physical findings obtained by the trainee; a discussion of the findings, significance and plans for management; major decisions relating to management and disposition; appropriate involvement with planning and performance of procedures; reassessment, follow-up and discharge.
For further information please contact
The Director of Registration and Professional Enhancement
The College of Physicians and Surgeons of Ontario
80 College Street
Toll free: 800-268-7096