LETTER
Preventing Adverse Events
Paul R. Casner
15 June 1995 | Volume 122 Issue 12 | Pages 962-964
TO THE EDITOR:
As a former program director, I read with interest the report by Petersen and colleagues [1] describing an association of adverse hospital events with cross-coverage by resident physicians. Although such studies may ultimately help to answer questions about work-hour reforms for housestaff, I believe it would be more helpful to design studies that focus attention on what should be the central issue in residency training in internal medicine: supervision. This point was recently emphasized in an editorial by Dr. Bertrand Bell [2], chair of the New York State Ad Hoc Advisory Committee, to which the authors referred in their report. This commentary was in response to a similar study that described an association of increased in-hospital complications after regulations restricting housestaff working hours had gone into effect in New York State [3].
If you were to ask a dozen internal medicine faculty what constitutes adequate resident supervision, you would probably get as many different answers. The current Residency Review Committee guidelines in internal medicine do not detail what constitutes faculty supervision [4]. This is in contrast to guidelines of other Residency Review Committees (for example, that for obstetrics), according to which faculty are now required to be in-hospital 24 hours a day [4].
How much supervision by attending faculty should residents in training have? Is internal medicine training analogous to the relationship of the apprentice to the master craftsman, with the craftsman watching the apprentice's every move, carefully directing the trainee and intervening before any serious mistakes are made? Is it necessary to allow residents in training to make mistakes? As a youth, I was taught that mistakes were among the most effective ways of learning because one would learn never to make the same mistake again. Do we risk harming the training experience of our housestaff by not allowing them to make some mistakes? If scientific investigations need to be conducted on resident training, investigations should be designed to answer questions about supervision, particularly faculty supervision.
Petersen and colleagues do not define the level of faculty supervision. The "responsible" physicians appear to be the interns.
1. Peterson LA, Brennan TA, O'Neill AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994; 121:866-72.
2. Bell BM. Supervision, not regulation of hours, is the key to improving the quality of patient care (Editorial). JAMA. 1993; 269:403-4.
3. Laine CL, Goldman C, Soukup JR, Hayes JG. The impact of a regulation restricting medical housestaff working hours on the quality of patient care. JAMA. 1993; 269:374-8.
4. Graduate Medical Education Directory 1994-1995. Special Requirements for Residency Education in Internal Medicine. Chicago: American Medical Association; 1994:48-9.
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