Farnan and colleagues highlight an important and delicate challenge for the supervision of medical trainees: determining the appropriate degree of oversight and involvement. An extremely “hands-off” approach, which was evident in some of the cases we examined, poses patient safety risks. Very close oversight, on the other hand, demeans the trainee, impedes learning, and stifles the development of independent clinical skills.
The “indirect supervision” to which Farnan and colleagues refer may be a useful strategy in negotiating between these undesirable extremes. Kennedy et al1 have recently proposed a new conceptual framework of clinical oversight by senior physicians to ensure quality of care. In this framework, supervisors may engage in various types of oversight, including “responsive oversight” (triggered “double checking” of patients' clinical condition) and “backstage oversight” (monitoring of which the trainees were unaware, such as checking laboratory values), which may occur even when residents discourage involvement by the attending physician. This work also acknowledges that when supervisors encounter a situation that exceeds a trainee's competence, they move beyond clinical oversight to direct patient care.