We commend Singh et al1 on their thought-provoking and important work. While we certainly agree that patient handoffs are rife with the potential for error and patient harm secondary to breakdowns in communication,2 laying the onus of supervision squarely on the attending physician is an issue we call into question.
The struggle between resident autonomy and the duty to supervise is constant, with trainees wishing to assert their independence and the hidden curriculum reinforcing their actions.3 Levels of supervision have been defined within specific specialties, such that there is a graded amount of attending physician involvement: direct, which requires the physical presence of the attending physician during the key aspect of patient care; participatory, with faculty providing oversight before or during the care of the patient; and indirect, which involves the faculty reviewing the care given to patients by examination of medical records or discussion of treatment plan.4 It is important to note that indirect supervision, which is most commonly adopted and used in nonprocedural specialties, can be misperceived as a lack of supervision in some cases. In these instances, residents may actively discourage involvement by the attending physician. In fact, an overly involved attending physician is perceived as invasive and having a lack of faith in the team's clinical competence.5 Moreover, the Accreditation Council for Graduate Medical Education stresses providing and promoting resident autonomy in clinical care.6 The control of the struggle between autonomy and supervision lies squarely with the resident physician, since they choose to engage their attending physician in their decision making. Often it is not that the attending physician is not participating in decision making because of a failure to supervise, but that they are not aware of the decisions being made by their resident.