Acad Psychiatry DOI 10.1007/s40596-014-0247-z
COLUMN: EDUCATIONAL RESOURCE
Direct Supervision in Outpatient Psychiatric Graduate Medical Education Cathryn A. Galanter & Roumen Nikolov & Norma Green & Shivana Naidoo & Michael F. Myers & Joseph P. Merlino
Received: 22 January 2014 / Accepted: 22 October 2014 # Academic Psychiatry 2014
Abstract Objective The authors describe a stimulus case that led training staff to examine and revise the supervision policy of the adult and child and adolescent psychiatry clinics. To inform the revisions, the authors reviewed the literature and national policies. Methods The authors conducted a literature review in PubMed using the following criteria: Supervision, Residents, Training, Direct, and Indirect and a supplemental review in Academic Psychiatry. The authors reviewed institutional and Accreditation Council for Graduate Medical Education resident and fellow supervision policies to develop an outpatient and fellow supervision policy. Results Research is limited in psychiatry with three experimental articles demonstrating positive impact of direct supervision and several suggesting different techniques for direct supervision. In other areas of medicine, direct supervision is associated with improved educational and patient outcomes. The authors present details of our new supervision policy including triggers for direct supervision. Conclusions The term direct supervision is relatively new in psychiatry and medical education. There is little published on the extent of implementation of direct supervision and on its impact on the educational experience of psychiatry trainees and other medical specialties. Direct supervision has been associated with improved educational and patient outcomes in nonpsychiatric fields of medicine. More research is needed on the implementation of, indications for, and effects of direct supervision on trainee education and on patient outcomes.
Keywords Supervision . Direct . Indirect . Training . Psychiatry . Residency-Child . Adolescent psychiatry fellowship In the general psychiatry residency and child and adolescent psychiatry (CAP) fellowship at our medical school, trainees spend a great deal of time at our academically affiliated city hospital. General psychiatry residents rotate in the hospital’s outpatient departments starting in their third postgraduate year (PGY), and CAP fellows begin outpatient at the end of their first year of fellowship, typically in their fourth or fifth postgraduate year. At times, the trainees receive direct supervision from attending physicians on their cases. More often, they receive indirect or oversight supervision. For this paper, we use supervision definitions consistent with the Accreditation Council for Graduate Medical Education (ACGME): direct supervision, where the supervising physician is physically present with the resident and patient; indirect supervision, where the supervising physician is immediately available (i.e., on site) or available (i.e., not on site but immediately available by phone or electronically); and oversight supervision, where the supervising physician is available to provide review after care is delivered [1]. What follows is a case that led us to reevaluate the supervision policy for our general psychiatry residents and child and adolescent psychiatry fellows.
Case C. A. Galanter (*) : R. Nikolov : N. Green : M. F. Myers : J. P. Merlino State University of New York (SUNY) Downstate and Kings County Hospital Center, Brooklyn, NY, USA e-mail: [email protected] S. Naidoo Hofstra North Shore-LIJ School of Medicine, Glen Oaks, NY, USA
A 16-year-old male teenager, recently immigrated and living with his mother and her boyfriend, presented to our clinic for continuation of treatment for aggressive behavior. Treatment had been initiated in his native country. He also had a neurological condition that had been diagnosed 8 years before. The disorder was characterized by the presence of multiple
Acad Psychiatry
difficult-to-manage seizures, evolving developmental delays and aggressive behavior, which contributed to his psychiatric condition. Following his initial evaluation by a staff clinician, he began psychotherapy and psychopharmacological treatment with a second-year child and adolescent psychiatry (CAP) fellow. He was simultaneously treated by a pediatric neurology resident. The CAP fellow treated the patient over the next 4 months with both psychopharmacology and psychotherapy. The fellow continued to prescribe the atypical antipsychotic risperidone that the patient had received previously. The psychotherapy treatment goals were to help establish an appropriate school placement, assist the patient in adapting to school, and decrease his aggression at home and school. The fellow and an attending board certified child and adolescent psychiatrist initially met weekly for oversight supervision, but, because of scheduling conflicts, they were not always able to keep to that schedule and ultimately met less frequently. The supervisor was on-site but not present (indirect supervision) at any of the patient visits, consistent with the supervisory policy of the clinic at the time. Rather, the supervisor made recommendations based on the fellow’s depiction of the patient’s history, mental status, and course of treatment as it unfolded. The fellow scheduled appointments with the patient with and without his mother weekly, but the patient and mother did not keep all regularly scheduled appointments. Their attendance was discussed during the oversight supervision. The CAP fellow worked with the patient on anger management, including discussions of warning signs, and helped the patient to explore his feelings and use of coping mechanisms. However, the anger outbursts continued both at home and school. The patient’s neurological condition remained unstable and led to a brief hospitalization. He became frustrated and morose over his neurological condition and was not adherent with neurological and psychotropic medication. His condition began to destabilize. As this occurred, his mother reported concerning behaviors to the neurology resident but did not report these to the CAP fellow. These behaviors included the medication nonadherence, lability of mood, and outbursts of anger. Though the two treating trainees communicated with each other, some of the concerning information did not get communicated adequately to the CAP fellow, and these communications did not involve either the neurology or psychiatry attending physician. Thus, at this point in the treatment, neither the CAP fellow nor the CAP attending were aware of the seriousness of the patient’s state. The patient’s condition deteriorated further. After a routine visit to the neurology clinic, he was referred to the Comprehensive Psychiatric Emergency Program (CPEP) because of suicidality and increased aggressiveness. At the CPEP, he was evaluated and treated by a senior child and
adolescent psychiatrist with the CAP fellow. They discussed a potential future change of medication for his outpatient providers to implement, and he was stabilized and released. The findings were discussed with the supervising attending physicians in oversight supervision. His medication was ultimately changed. The risperidone was tapered, and fluoxetine was started. He appeared to improve. However, several weeks later, he acted aggressively at school leading to a severe injury to another person. We do not know if direct supervision would have changed the outcome, but a review of the events led us to critically review the literature and guidelines on outpatient psychiatry supervision and to revise our clinic’s policy for outpatient supervision of trainees.
History of Outpatient Supervision Psychotherapy supervision has traditionally been considered the means by which trainees learn to become effective psychotherapists [2]. Supervision as defined by Yogev is “the function of overseeing the counselor’s work for the purpose of facilitating personal and professional development, improving competence and promoting accountability in counseling and guidance” [3]. Historically, psychiatry residents were encouraged to “do psychotherapy” by being alone with the patient and applying lessons and theory learned through readings, didactic lectures, and supervision. Rates of direct supervision have not been well studied or documented, yet direct supervision for outpatient assessment and psychotherapy appears to be limited. The rationale was that the trainee’s autonomy was encouraged, and his or her mastery of the technical aspects of the practice of psychotherapy was enhanced by this type of supervision. Likewise, the therapeutic alliance was not disturbed by having an extra person in the room. Process notes were generally recorded during or immediately after the psychotherapy session and read or summarized during the formal supervisory process which typically occurred on a weekly basis and in which one or more of the trainees presented cases. Supervisors might discuss formulation, choosing the appropriate type of psychotherapy and implementation of techniques. This method of supervision recognized the working relationship of the supervisor and supervisee as the milieu of learning. It called upon the supervisor to monitor the relationship between the trainee and supervisor [4], to be attuned to the trainee’s blind spots, and to recognize the possibility that enactments or parallel processes might take place. Further, it relied upon the supervisor-supervisee pair to have a good working relationship in which problems in the treatment could be exposed and discussed [4, 5]. It presupposed that trainees would present with a range of competencies and interests and a range of abilities to honestly present their work. It took into
Acad Psychiatry
consideration that they might also be defensive, for example, by not being open to feedback from their supervisor. There were several limitations with the traditional (oversight) supervision. The trainee could only report on what he “saw” and “heard” in his sessions with the patient. Thus, the trainee was at risk for blind spots due to lack of experience, personal dynamics, or the phenomena of transference and countertransference. The best supervisor could only work with the material presented and could likewise miss pertinent findings that were not presented. Another limitation of this model was that the trainee’s progression of independence was often based on training year, and thus, trainees may have been given more autonomy based on postgraduate year instead of skill progression. A fellow may have been given more latitude than a resident in his or her third postgraduate year who in turn was given more autonomy than a second year resident. Years in training may not equate with advanced technical expertise. Much of the success of this method depended on the program and supervisor’s ability to assess the strengths and weaknesses of the trainees and supervisors. The Introduction of Direct, Indirect, Oversight Framework by the ACGME Direct supervision did not become a routine part of educational policy until recently. The ACGME common program requirements from 2003 stated, “All patient care must be supervised by qualified faculty” and that “[r]esidents must be provided with rapid, reliable systems for communicating with faculty” [6]. Due to concern over resident work hours and sufficiency of supervision, the Institute of Medicine convened a committee to examine graduate medical education. The result, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, called for increased direct supervision of residents [7]. ACGME expectations around the level of supervision increased, and the 2011 ACGME regulations included a much higher standard for resident supervision [1]. As part of the 2011 common program requirements, the ACGME introduced the three levels of supervision: direct, indirect, and oversight (defined in paragraph one of the background) [1]. These new guidelines were also incorporated into the general psychiatry requirements [8] and the child and adolescent psychiatry program requirements [9]. Benchmarks for Increased Trainee Autonomy With these ACGME requirements, the program director and faculty were tasked with determining when trainees were ready to transition to increased autonomy, also known as progressive authority. Each (sub)specialty review committee was charged to give specific definitions for levels of supervision. For example, the Psychiatry Residency Review
Committee (PRRC) defined four specific criteria for a PGY1 resident to advance from direct supervision to indirect supervision (with direct supervision available) after demonstrating competence in the following: (1) the ability and willingness to ask for help when indicated, (2) gathering an appropriate history, (3) the ability to perform an emergent psychiatric assessment, and (4) presenting patient findings and data accurately to a supervisor who has not seen the patient [8]. However, the ACGME and RRC did not specify competencies for advancing from PGY2 to beyond. Thus, training programs had leeway to make these decisions and determined advancement in different ways. These progressive transitions were also further complicated in child and adolescent psychiatry and other subspecialty training. In these settings, fellows may have acquired the requisite skills in their specialty but not in their subspecialty. A first-year child and adolescent psychiatry fellow might have become competent in assessment and treatment with adults, but not in child and adolescent psychiatry, where one must interpret symptoms and diagnoses across developmental levels and integrate information from multiple informants. Additionally, fellows from different general residency programs may have had different clinical and didactic experiences. Thus, competencies may vary among fellows across domains. Patient factors such as illness complexity and ability to communicate relevant history are likely to affect the trainee’s ability to manage assessment and treatment. For example, a trainee might have been able to achieve the benchmarks of PGY1 competency for a straightforward case but not for a more complex one. Additionally, a more experienced trainee may be more confident and thus less likely to identify the need for increased supervisory assistance. For our training programs, the question remained, when could we decide that a psychiatry resident was competent enough to not require direct supervision? And similarly, what were the clinical scenarios that required direct outpatient supervision? We set out to examine the evidence supporting direct supervision in psychiatry and to use these data to inform our outpatient supervision policy.
Methods We reviewed the literature and also identified the practice of oversight supervision in our outpatient psychiatric clinics as a potential contributing factor to adverse outcomes. We assembled a workgroup to review our current institutional resident supervision policies and practices, the documents related to supervision of psychiatry trainees in outpatient settings, and the extant literature. For our literature search, we used PubMed as the primary database using the following keyword criteria: Supervision,
Acad Psychiatry
Residents, Training, Direct, or Indirect. From this search, we reviewed 408 titles. From this list, we chose those abstracts and articles that addressed these different methods of supervision of residents, resulting in 30 abstracts and articles to read in full. In addition, we conducted a literature search of Academic Psychiatry using search terms Residency and Supervision and limiting our search to the past 10 years that resulted in 108 titles. We reviewed all of the abstracts and from these, read the 13 relevant manuscripts. Thus, we reviewed a total of 516 titles (excluding overlap) and 43 manuscripts that addressed direct and indirect supervision of residents and fellows. In developing our new supervision guidelines, we reviewed our current policy and the recommendations from the ACGME and our graduate medical education department. On the basis of the above review, the index case, and clinical consensus, we created a supervision policy that defined the clinical situations requiring direct supervision on our outpatient psychiatric service. We then mapped the clinical process in the psychiatric outpatient service and identified situations (nodal points) where direct attending supervision would be necessary due to patient risk or nonresponse to treatment.
Results Direct Supervision in Outpatient Psychiatric Education Our literature review identified three early studies in psychiatry that compared supervision types and the impact on educational and patient outcomes [10–12]. Stein and colleagues [10] studied direct versus oversight supervision of evaluations and found greater agreement regarding severity of psychopathology when both the supervisor and resident were present. The authors concluded that a supervisor who did not directly evaluate the patient was “handicapped” in his or her evaluation of the patient. Another study examined whether senior staff supervision of residents conducting outpatient evaluations improved outcome in comparison to evaluations done by “non-supervised” trainees [11]. This study found that patient outcomes were significantly better for patients evaluated by [directly] supervised trainees. Another study compared 4month outcomes of patients who were assessed by residents under direct and indirect supervision [12]. The authors found that when residents were earlier in their training, directly supervised assessments led to better patient outcomes as indicated by more patients who were still in treatment or who had been in successfully terminated treatment and by having a better outcome. Interestingly, few recent studies have examined the impact of direct supervision in psychiatry or child and adolescent psychiatry training. A review of articles from Academic Psychiatry resulted in several articles that address different
modalities of supervision such as the use of audiotape [13,14] or the importance of assessing trainees work samples by audio tape or written case conceptualizations [15] or the use of different approaches to the supervisor being present such as telepsychiatry [16] or standardized patients [17,18]. Young and colleagues [19] drew on the medical education literature supporting direct supervision and developed a structured clinical observation tool to assess pharmacotherapy competency. We were unable to find any additional articles that explicitly examined or reviewed the impact or benefits of direct supervision in psychiatry training. Direct Supervision in Other Specialties Investigators have also examined the impact of direct and indirect supervision in other fields of medical training. A systematic review of supervision of residents across many fields found that direct supervision of residents promoted positive changes in both patient care and education, particularly during procedure-based clinical training [20]. Studies indicated a clear impact of direct supervision on adequate utilization management (decreased utilization of ICU [21] and increased hospital discharges [22]), decreases in medical errors [20], and stronger compliance with care management protocols [22, 23]. Studies examining the impact of supervision type on patient outcome have conflicting results, however, with direct supervision correlating with fewer complications and decreased mortality in some studies [22,24], but higher complication rates and no significant mortality difference in others [25]. Importantly, residents in internal and rehabilitation medicine have cited the amount of direct supervision in their training programs to be a significant factor in valuing their program and thinking highly of the educational experience [26,27]. Supervision Policy We developed a department-wide supervision policy for all of the outpatient behavioral health clinics at our universityaffiliated city hospital (the full policy is available from the authors on request). The policy requires that supervisors and trainees meet weekly for oversight supervision and that if either party is unable to meet, the supervisor determines if there is a need to meet before the following week’s supervision. It also states explicitly that supervisors are responsible for all final pharmacological and other psychotherapeutic treatment decisions. Particularly germane to this discussion, our policy identifies specific triggers for direct supervision. For intake evaluations of new patients, attending physician supervisors are required to provide direct supervision so that they can directly assess the patient and the trainee’s assessment of the patient. Initially, faculty are present for the full evaluation, but
Acad Psychiatry
once they determine the fellow is competent to adequately gather and convey mental status and history, they are present for only part of the evaluation so that they can assess mental status and address any of their outstanding questions. Additionally, for patients who have been discharged from the CPEP or from a hospitalization, attending physician supervisors are required to meet face-to-face with the trainee and patient at reentry to outpatient services and provide direct supervision so that care decisions are informed by the attending physician’s participation in the risk assessment and mental status examination. The policy governs supervision in both the adult and the child and adolescent ambulatory psychiatry clinics. There are no significant differences in the policy provisions for supervision of treatment by trainees of adult and child and adolescent psychiatric patients. The new policy defines the methods of supervision exercised as direct, indirect, and oversight (consistent with ACGME definitions). For ongoing cases in child and adolescent psychiatry, we developed a set of triggers for direct supervision. These include (1) patients who had been discharged from the CPEP or the inpatient psychiatry service; (2) periodic direct supervision on ongoing continuity cases; (3) when after feedback from the supervisor, the trainee was unable to clearly report findings from the mental status exam or the patient’s history in a way that made clear to the supervisor the patient’s diagnosis and clinical status; (4) when there was an elevation of risk status that did not respond to those interventions discussed during oversight or indirect supervision and implemented by the trainee; (5) to resolve conflicts or concerns raised by patients, parents, or guardians between the patient, parent, or guardian and the trainee that cannot be resolved by the trainee after indirect or oversight supervision. After we developed our guidelines, they were reviewed and accepted by our hospital administration as policy. Additionally, they were reviewed with fellows at the weekly fellows’ meeting and with the clinic’s teaching staff at the biweekly administrative meeting. They have been also incorporated into the child and adolescent psychiatry fellowship handbook.
Discussion One of our trainees and his supervising attending physician treated a patient who had an untoward outcome. We identified our supervision policy as a possible contributor. This led us to review our supervision policy and the extant literature on direct, indirect, and oversight supervision. After conducting a systematic review of the literature on direct and indirect supervision in psychiatric and other graduate medical education, we determined that the term direct
supervision was relatively new in psychiatry, and there was little published on the impact of direct supervision on the educational experience of psychiatry trainees or trainees in other medical specialties. One study found greater agreement when both the supervisor and resident observed the interview, and two other studies found that patient outcomes were better when residents were directly supervised. In other areas of medicine, several studies indicated that direct supervision has been associated with both improved educational and patient outcomes. We revised our supervision policy to increase direct supervision, especially as part of initial assessment and in higherrisk situations as part of ongoing treatment. We elected to identify specific situations that would require direct supervision but did not make direct supervision a requirement for all clinical encounters. We now require direct supervision for all new evaluations whereby the attending physician is present to directly assess the patient and the trainee’s assessment of the patient. Initially, faculty is present for the full evaluation but once the faculty member determines the fellow is competent to adequately gather and convey mental status and history, the faculty is present for only part of the evaluation in order to assess mental status and address any outstanding questions. We also identified specific (higher-risk) situations in ongoing care that would trigger an attending physician to provide direct supervision. These triggers take into account individual trainees’ skills and patient risk factors. These policies were sustainable for our program, and we encourage other programs to assess whether they may be right for their programs. The data are limited, but these positive studies raise the question of why there is no greater implementation of direct supervision in psychiatry training programs. Our review led us to believe that several factors contributed to limited widespread implementation of direct supervision including following the status quo, which in psychiatry was oversight supervision and had been perceived as being effective in most situations, the desire to foster trainee’s autonomy, to preserve the perception of confidentiality, limited guidelines and regulations regarding direct supervision. Additionally, ACGME addresses the transition of supervision in the first to second year of training; however, transitions later in training are not addressed. Our literature search using direct and indirect supervision did not identify articles on the impact of regulatory and fiscal realities on supervision, yet they may also impact on supervision policy. Individual supervision time is among the largest personnel-related expenses for training programs [28]. Teaching hospitals receive reimbursement for “direct costs” they incur in training physicians: salaries, teaching, supervision, and overhead. The Medicare program reimburses teaching hospitals for a portion of these expenses through direct graduate medical education (DGME) payments.
Acad Psychiatry
Medicare does not make GME payments for outpatient services, but it may reimburse for outpatient services provided by trainees. Certain states and insurance policies require the attending physician’s presence in the room with the patient in order to reimburse for service. Other states, including New York, follow Medicare rules when using Medicaid funds to pay for outpatient services furnished by residents and allow payment for outpatient care furnished by residents without the physical presence of the attending physician [29]. The Center for Medicare & Medicaid Services (CMS) recently decided to reduce its supervision requirement from direct to oversight as a concession to small rural hospitals with difficulty meeting the staffing needed to be compliant with a direct supervision requirement [30]. CMS’s actions raised concern in the American Psychiatric Association that the new supervision standards were “too lax” to ensure delivery of safe and effective care [31]. Current GME payment structure is blind to the type or amount of supervision an individual resident needs or receives. The payment rates for subspecialty training assume that advanced trainees would need and utilize less training resources. Hence, at most institutions, there is inherent tension between faculty time allocated for direct care and trainee supervision, as one is seen as revenue generating and the other is not. Wider use of direct supervision in psychiatry training has the potential to ease some of this tension. Further investigation is needed to determine direct supervision if a higher fee-for-service reimbursement for directly supervised patient encounters would result in higher patient satisfaction, better retention in treatment, and fewer adverse treatment events. Additionally, whether these more intangible outcomes would offset lost revenue from unrealized faculty direct care encounters needs further study. Our change in policy was not designed to measure if guidelines on direct supervision improved patient care and the trainee’s educational experience. Further research is needed in order to examine the impact of different types of supervision on trainee education and patient outcomes. In our experience, the implementation of our policy has added an average of 1 hour of direct supervision per faculty member per week to the 1 hour of oversight supervision per trainee expected as minimum supervision effort. This hour is at the expense of individual faculty member productivity. We recognize that financial and workforce realities may vary with each institution, limiting the ability to extend direct supervision resource. We strongly believe that the potential gains in educational outcomes, patient safety, and patient satisfaction make the consideration of a direct supervision policy worthwhile. The financial impact of implementing direct supervision, finding ways to measure the indirect benefits (including financial) of direct supervision in psychiatry, and the most efficient ways to dose and deliver direct supervision merits further study.
Our experience raised for us the question of whether more specific guidelines from the ACGME on when direct supervision should be required would improve resident education and patient care. The new ACGME milestones for general psychiatry include anchors that describe increasing skill levels [32, 33]. These anchors are not tied back to progressive authority. The field would benefit from further research and guidance on the level of training (based on years, skills, and milestone levels) and clinical situations where direct supervision is required and whether where more advanced residents and patients would benefit from further autonomy. Similarly, we would benefit from research evaluating whether these new milestones are valid and effective in assessing trainee skill and readiness for progression. Potential negative impact on trainees developing more independence and autonomy needs further study. Given the limited guidelines from the ACGME, the implementation of direct supervision in outpatient psychiatry is left to the discretion of the training program and likely varies. There are also limited data on how often and in what circumstances direct supervision is used in both general and child and adolescent psychiatry training programs, both historically and currently. This, too, needs further study. Acknowledgments The authors gratefully acknowledge Sabina Singh, M.D. for her contribution in developing our supervision policy and Barbara Gamboni-Silva for her administrative assistance in preparing this manuscript. Disclosures Drs. Green, Merlino, Naidoo, and Nikolov have nothing to disclose. Dr. Galanter receives royalties from American Psychiatric Publishing, Inc. and is on the scientific steering committee of the REsource for Advancing Children’s Health (REACH) Institute.
References 1. Common Program Requirements, Effective July 1 2011. http:// acgme-2010standards.org/pdf/Common_Program_Requirements_ 07012011.pdf. Accessed 6/4/2013. 2. Watkins CE. Psychotherapy supervision in the 21st century. J Psychother Pract Res. 1998;7:93–101. 3. Yogev S. An eclectic model of supervision: a developmental sequence for beginning psychotherapy students. Prof Psychol. 1982; 13:2. 4. Baudry FD. The personal dimension and management of the supervisory situation with a special note on the parallel process. Psychoanal Q. 1993;62:588–614. 5. Kernberg OF. Psychoanalytic supervison: the supervisor’s tasks. Psychoanal Q. 2010;79:603–27. 6. ACGME. Graduate medical education directory 2003–2004. Chicago: AMA Press; 2003. 7. Ulmer C, Wolman DM, Johns MME. In: Resident Duty Hours: Enhancing Sleep, Supervision and Safety (IOM 2009) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, editors. National Research Council. 8. ACGME Review Committee for Psychiatry. ACGME Program requirements for Graduate Medical Education in Psychiatry, https://
Acad Psychiatry
9.
10. 11. 12.
13.
14.
15.
16.
17. 18.
19.
20.
w w w. a c g m e . o r g / a c g m e w e b / P o r t a l s / 0 / P FA s s e t s / ProgramRequirements/400_psychiatry_07012007_u04122008. pdf(2011). Reviewed 12 June 2014. ACGME Review Committee for Psychiatry. ACGME Program requirements for Graduate Medical Education in Child and Adolescent Psychiatry, (http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/405pr07012007.pdf) (2011). Reviewed 6 May 2013. Stein SP, Karasu TB, Charles ES, Buckley PJ. Supervision of the Initial Interview. Arch Gen Psychiatry. 1975;32:265–8. Kass F, et.al. Assessing the impact of supervision on outpatient evaluation in psychiatry, QRB. 1984; 3–5. Jaynes S, Charles E, Kass F, Holzman F. Clinical supervision of the initial interview: effects on patient care. Am J Psychiatry. 1979;136: 1454–7. Krasner RF, Shelby SR, Howard KI. Are advanced psychiatry residents more skillful than beginning residents in the conduct of psychodynamic psychotherapy. Acad Psychiatry. 1999;23:88–94. Weerasekera P, Antony MM, Bellissimo A, Bieling P, Shurina-Egan J, Spencer A, et al. Competency assessment in the McMaster psychotherapy program. Acad Psychiatry. 2003;27:166–73. Sudak DM, Goldberg DA. Trends in psychotherapy training: a national survey of psychiatry residency training. Acad Psychiatry. 2013;36:369–73. Szeftel R, Hakak R, Meyer S, Naqvi S, Sulman-Smith H, Delrahim K, et al. Training psychiatric residents and fellows in a telepsychiatry clinic: a supervision model. Acad Psychiatry. 2008;32:393–9. Mellsop GW, MacDonald J, El Badri S, Menkes D. Patients’ appraisal of psychiatric trainee interview skills. Acad Psychiatry:. 2012;36:374–9. Ravitz P, Lancee WJ, Lawson A, Maunder R, Hunter JJ, Leszcz M, et al. Improving physician–patient communication through coaching of simulated encounters. Acad Psychiatry. 2013;37:87–93. Young JQ, Lieu S, O’Sullivan P, Tong L. Development and initial testing of a structured clinical observation tool to assess pharmacotherapy competence. Acad Psychiatry. 2011;35:27–34. Farnan JM, Petty LA, Georgitis E, Martin S, Chiu E, Prochaska M, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428–42.
21. Durham R, Shapiro D, Flint L. In-house trauma attendings: is there a difference? Am J Surg. 2005;190:960–6. 22. Claridge JA, Carter JW, McCoy AM, Malangoni MA. In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury. Surgery. 2011;150:718–26. 23. Sox CM, Burstin HR, Orav EJ, Conn A, Setnik G, Rucker DW, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998;73(7):776–82. 24. de Oliveira Filho GR, Dexter F. Interpretation of the association between frequency of self-reported medical errors and faculty supervision of anesthesiology residents. Anesth Analg. 2013;116:752–3. 25. Demarest GB, Scannell G, Sanchez K, Dziwulski A, Qualls C, Schermer CR, et al. In -house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999;46:535–40. 26. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005;16:2607–13. 27. Lascano CA, Stovak ML, Harvey AT. Direct versus indirect supervision of fellows covering football events: a survey of fellows and program directors. J Grad Med Educ. 2010;2:442–8. 28. Magen J, Banazac D. The cost of residency training in psychiatry. Acad Psychiatry. 2000;24:195–201. 29. DHHS/CMC. Guidelines for Teaching Physicians, Interns, and Residents, Fact Sheet. 2011. http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/ downloads/gdelinesteachgresfctsht.pdf. Accessed 4/9/2013. 30. Centers for Medicare and Medicaid Services. CMS’ final decisions on the recommendations of the hospital outpatient payment panel on supervision levels for select services, (May 22 2012), retrieved May 23, 2013, website: www.cms.gov/Regulations-and-Guidance/ Guidance/FACA/Downloads/PrelimSupervisionDecisions.pdf. 31. Wolfe J. “Outpatient supervision standards too lax, APA tells CMS,” Psychiatr News, 2012; 9. 32. Thomas CR. Educational milestone development for psychiatry. J Grad Med Educ. 2014;6(1s1):281–3. 33. The Psychiatry Milestone Project. J Grad Med Educ. 2014; 6 1s1: 284–304.
COLUMN: EDUCATIONAL RESOURCE
Direct Supervision in Outpatient Psychiatric Graduate Medical Education Cathryn A. Galanter & Roumen Nikolov & Norma Green & Shivana Naidoo & Michael F. Myers & Joseph P. Merlino
Received: 22 January 2014 / Accepted: 22 October 2014 # Academic Psychiatry 2014
Abstract Objective The authors describe a stimulus case that led training staff to examine and revise the supervision policy of the adult and child and adolescent psychiatry clinics. To inform the revisions, the authors reviewed the literature and national policies. Methods The authors conducted a literature review in PubMed using the following criteria: Supervision, Residents, Training, Direct, and Indirect and a supplemental review in Academic Psychiatry. The authors reviewed institutional and Accreditation Council for Graduate Medical Education resident and fellow supervision policies to develop an outpatient and fellow supervision policy. Results Research is limited in psychiatry with three experimental articles demonstrating positive impact of direct supervision and several suggesting different techniques for direct supervision. In other areas of medicine, direct supervision is associated with improved educational and patient outcomes. The authors present details of our new supervision policy including triggers for direct supervision. Conclusions The term direct supervision is relatively new in psychiatry and medical education. There is little published on the extent of implementation of direct supervision and on its impact on the educational experience of psychiatry trainees and other medical specialties. Direct supervision has been associated with improved educational and patient outcomes in nonpsychiatric fields of medicine. More research is needed on the implementation of, indications for, and effects of direct supervision on trainee education and on patient outcomes.
Keywords Supervision . Direct . Indirect . Training . Psychiatry . Residency-Child . Adolescent psychiatry fellowship In the general psychiatry residency and child and adolescent psychiatry (CAP) fellowship at our medical school, trainees spend a great deal of time at our academically affiliated city hospital. General psychiatry residents rotate in the hospital’s outpatient departments starting in their third postgraduate year (PGY), and CAP fellows begin outpatient at the end of their first year of fellowship, typically in their fourth or fifth postgraduate year. At times, the trainees receive direct supervision from attending physicians on their cases. More often, they receive indirect or oversight supervision. For this paper, we use supervision definitions consistent with the Accreditation Council for Graduate Medical Education (ACGME): direct supervision, where the supervising physician is physically present with the resident and patient; indirect supervision, where the supervising physician is immediately available (i.e., on site) or available (i.e., not on site but immediately available by phone or electronically); and oversight supervision, where the supervising physician is available to provide review after care is delivered [1]. What follows is a case that led us to reevaluate the supervision policy for our general psychiatry residents and child and adolescent psychiatry fellows.
Case C. A. Galanter (*) : R. Nikolov : N. Green : M. F. Myers : J. P. Merlino State University of New York (SUNY) Downstate and Kings County Hospital Center, Brooklyn, NY, USA e-mail: [email protected] S. Naidoo Hofstra North Shore-LIJ School of Medicine, Glen Oaks, NY, USA
A 16-year-old male teenager, recently immigrated and living with his mother and her boyfriend, presented to our clinic for continuation of treatment for aggressive behavior. Treatment had been initiated in his native country. He also had a neurological condition that had been diagnosed 8 years before. The disorder was characterized by the presence of multiple
Acad Psychiatry
difficult-to-manage seizures, evolving developmental delays and aggressive behavior, which contributed to his psychiatric condition. Following his initial evaluation by a staff clinician, he began psychotherapy and psychopharmacological treatment with a second-year child and adolescent psychiatry (CAP) fellow. He was simultaneously treated by a pediatric neurology resident. The CAP fellow treated the patient over the next 4 months with both psychopharmacology and psychotherapy. The fellow continued to prescribe the atypical antipsychotic risperidone that the patient had received previously. The psychotherapy treatment goals were to help establish an appropriate school placement, assist the patient in adapting to school, and decrease his aggression at home and school. The fellow and an attending board certified child and adolescent psychiatrist initially met weekly for oversight supervision, but, because of scheduling conflicts, they were not always able to keep to that schedule and ultimately met less frequently. The supervisor was on-site but not present (indirect supervision) at any of the patient visits, consistent with the supervisory policy of the clinic at the time. Rather, the supervisor made recommendations based on the fellow’s depiction of the patient’s history, mental status, and course of treatment as it unfolded. The fellow scheduled appointments with the patient with and without his mother weekly, but the patient and mother did not keep all regularly scheduled appointments. Their attendance was discussed during the oversight supervision. The CAP fellow worked with the patient on anger management, including discussions of warning signs, and helped the patient to explore his feelings and use of coping mechanisms. However, the anger outbursts continued both at home and school. The patient’s neurological condition remained unstable and led to a brief hospitalization. He became frustrated and morose over his neurological condition and was not adherent with neurological and psychotropic medication. His condition began to destabilize. As this occurred, his mother reported concerning behaviors to the neurology resident but did not report these to the CAP fellow. These behaviors included the medication nonadherence, lability of mood, and outbursts of anger. Though the two treating trainees communicated with each other, some of the concerning information did not get communicated adequately to the CAP fellow, and these communications did not involve either the neurology or psychiatry attending physician. Thus, at this point in the treatment, neither the CAP fellow nor the CAP attending were aware of the seriousness of the patient’s state. The patient’s condition deteriorated further. After a routine visit to the neurology clinic, he was referred to the Comprehensive Psychiatric Emergency Program (CPEP) because of suicidality and increased aggressiveness. At the CPEP, he was evaluated and treated by a senior child and
adolescent psychiatrist with the CAP fellow. They discussed a potential future change of medication for his outpatient providers to implement, and he was stabilized and released. The findings were discussed with the supervising attending physicians in oversight supervision. His medication was ultimately changed. The risperidone was tapered, and fluoxetine was started. He appeared to improve. However, several weeks later, he acted aggressively at school leading to a severe injury to another person. We do not know if direct supervision would have changed the outcome, but a review of the events led us to critically review the literature and guidelines on outpatient psychiatry supervision and to revise our clinic’s policy for outpatient supervision of trainees.
History of Outpatient Supervision Psychotherapy supervision has traditionally been considered the means by which trainees learn to become effective psychotherapists [2]. Supervision as defined by Yogev is “the function of overseeing the counselor’s work for the purpose of facilitating personal and professional development, improving competence and promoting accountability in counseling and guidance” [3]. Historically, psychiatry residents were encouraged to “do psychotherapy” by being alone with the patient and applying lessons and theory learned through readings, didactic lectures, and supervision. Rates of direct supervision have not been well studied or documented, yet direct supervision for outpatient assessment and psychotherapy appears to be limited. The rationale was that the trainee’s autonomy was encouraged, and his or her mastery of the technical aspects of the practice of psychotherapy was enhanced by this type of supervision. Likewise, the therapeutic alliance was not disturbed by having an extra person in the room. Process notes were generally recorded during or immediately after the psychotherapy session and read or summarized during the formal supervisory process which typically occurred on a weekly basis and in which one or more of the trainees presented cases. Supervisors might discuss formulation, choosing the appropriate type of psychotherapy and implementation of techniques. This method of supervision recognized the working relationship of the supervisor and supervisee as the milieu of learning. It called upon the supervisor to monitor the relationship between the trainee and supervisor [4], to be attuned to the trainee’s blind spots, and to recognize the possibility that enactments or parallel processes might take place. Further, it relied upon the supervisor-supervisee pair to have a good working relationship in which problems in the treatment could be exposed and discussed [4, 5]. It presupposed that trainees would present with a range of competencies and interests and a range of abilities to honestly present their work. It took into
Acad Psychiatry
consideration that they might also be defensive, for example, by not being open to feedback from their supervisor. There were several limitations with the traditional (oversight) supervision. The trainee could only report on what he “saw” and “heard” in his sessions with the patient. Thus, the trainee was at risk for blind spots due to lack of experience, personal dynamics, or the phenomena of transference and countertransference. The best supervisor could only work with the material presented and could likewise miss pertinent findings that were not presented. Another limitation of this model was that the trainee’s progression of independence was often based on training year, and thus, trainees may have been given more autonomy based on postgraduate year instead of skill progression. A fellow may have been given more latitude than a resident in his or her third postgraduate year who in turn was given more autonomy than a second year resident. Years in training may not equate with advanced technical expertise. Much of the success of this method depended on the program and supervisor’s ability to assess the strengths and weaknesses of the trainees and supervisors. The Introduction of Direct, Indirect, Oversight Framework by the ACGME Direct supervision did not become a routine part of educational policy until recently. The ACGME common program requirements from 2003 stated, “All patient care must be supervised by qualified faculty” and that “[r]esidents must be provided with rapid, reliable systems for communicating with faculty” [6]. Due to concern over resident work hours and sufficiency of supervision, the Institute of Medicine convened a committee to examine graduate medical education. The result, Resident Duty Hours: Enhancing Sleep, Supervision and Safety, called for increased direct supervision of residents [7]. ACGME expectations around the level of supervision increased, and the 2011 ACGME regulations included a much higher standard for resident supervision [1]. As part of the 2011 common program requirements, the ACGME introduced the three levels of supervision: direct, indirect, and oversight (defined in paragraph one of the background) [1]. These new guidelines were also incorporated into the general psychiatry requirements [8] and the child and adolescent psychiatry program requirements [9]. Benchmarks for Increased Trainee Autonomy With these ACGME requirements, the program director and faculty were tasked with determining when trainees were ready to transition to increased autonomy, also known as progressive authority. Each (sub)specialty review committee was charged to give specific definitions for levels of supervision. For example, the Psychiatry Residency Review
Committee (PRRC) defined four specific criteria for a PGY1 resident to advance from direct supervision to indirect supervision (with direct supervision available) after demonstrating competence in the following: (1) the ability and willingness to ask for help when indicated, (2) gathering an appropriate history, (3) the ability to perform an emergent psychiatric assessment, and (4) presenting patient findings and data accurately to a supervisor who has not seen the patient [8]. However, the ACGME and RRC did not specify competencies for advancing from PGY2 to beyond. Thus, training programs had leeway to make these decisions and determined advancement in different ways. These progressive transitions were also further complicated in child and adolescent psychiatry and other subspecialty training. In these settings, fellows may have acquired the requisite skills in their specialty but not in their subspecialty. A first-year child and adolescent psychiatry fellow might have become competent in assessment and treatment with adults, but not in child and adolescent psychiatry, where one must interpret symptoms and diagnoses across developmental levels and integrate information from multiple informants. Additionally, fellows from different general residency programs may have had different clinical and didactic experiences. Thus, competencies may vary among fellows across domains. Patient factors such as illness complexity and ability to communicate relevant history are likely to affect the trainee’s ability to manage assessment and treatment. For example, a trainee might have been able to achieve the benchmarks of PGY1 competency for a straightforward case but not for a more complex one. Additionally, a more experienced trainee may be more confident and thus less likely to identify the need for increased supervisory assistance. For our training programs, the question remained, when could we decide that a psychiatry resident was competent enough to not require direct supervision? And similarly, what were the clinical scenarios that required direct outpatient supervision? We set out to examine the evidence supporting direct supervision in psychiatry and to use these data to inform our outpatient supervision policy.
Methods We reviewed the literature and also identified the practice of oversight supervision in our outpatient psychiatric clinics as a potential contributing factor to adverse outcomes. We assembled a workgroup to review our current institutional resident supervision policies and practices, the documents related to supervision of psychiatry trainees in outpatient settings, and the extant literature. For our literature search, we used PubMed as the primary database using the following keyword criteria: Supervision,
Acad Psychiatry
Residents, Training, Direct, or Indirect. From this search, we reviewed 408 titles. From this list, we chose those abstracts and articles that addressed these different methods of supervision of residents, resulting in 30 abstracts and articles to read in full. In addition, we conducted a literature search of Academic Psychiatry using search terms Residency and Supervision and limiting our search to the past 10 years that resulted in 108 titles. We reviewed all of the abstracts and from these, read the 13 relevant manuscripts. Thus, we reviewed a total of 516 titles (excluding overlap) and 43 manuscripts that addressed direct and indirect supervision of residents and fellows. In developing our new supervision guidelines, we reviewed our current policy and the recommendations from the ACGME and our graduate medical education department. On the basis of the above review, the index case, and clinical consensus, we created a supervision policy that defined the clinical situations requiring direct supervision on our outpatient psychiatric service. We then mapped the clinical process in the psychiatric outpatient service and identified situations (nodal points) where direct attending supervision would be necessary due to patient risk or nonresponse to treatment.
Results Direct Supervision in Outpatient Psychiatric Education Our literature review identified three early studies in psychiatry that compared supervision types and the impact on educational and patient outcomes [10–12]. Stein and colleagues [10] studied direct versus oversight supervision of evaluations and found greater agreement regarding severity of psychopathology when both the supervisor and resident were present. The authors concluded that a supervisor who did not directly evaluate the patient was “handicapped” in his or her evaluation of the patient. Another study examined whether senior staff supervision of residents conducting outpatient evaluations improved outcome in comparison to evaluations done by “non-supervised” trainees [11]. This study found that patient outcomes were significantly better for patients evaluated by [directly] supervised trainees. Another study compared 4month outcomes of patients who were assessed by residents under direct and indirect supervision [12]. The authors found that when residents were earlier in their training, directly supervised assessments led to better patient outcomes as indicated by more patients who were still in treatment or who had been in successfully terminated treatment and by having a better outcome. Interestingly, few recent studies have examined the impact of direct supervision in psychiatry or child and adolescent psychiatry training. A review of articles from Academic Psychiatry resulted in several articles that address different
modalities of supervision such as the use of audiotape [13,14] or the importance of assessing trainees work samples by audio tape or written case conceptualizations [15] or the use of different approaches to the supervisor being present such as telepsychiatry [16] or standardized patients [17,18]. Young and colleagues [19] drew on the medical education literature supporting direct supervision and developed a structured clinical observation tool to assess pharmacotherapy competency. We were unable to find any additional articles that explicitly examined or reviewed the impact or benefits of direct supervision in psychiatry training. Direct Supervision in Other Specialties Investigators have also examined the impact of direct and indirect supervision in other fields of medical training. A systematic review of supervision of residents across many fields found that direct supervision of residents promoted positive changes in both patient care and education, particularly during procedure-based clinical training [20]. Studies indicated a clear impact of direct supervision on adequate utilization management (decreased utilization of ICU [21] and increased hospital discharges [22]), decreases in medical errors [20], and stronger compliance with care management protocols [22, 23]. Studies examining the impact of supervision type on patient outcome have conflicting results, however, with direct supervision correlating with fewer complications and decreased mortality in some studies [22,24], but higher complication rates and no significant mortality difference in others [25]. Importantly, residents in internal and rehabilitation medicine have cited the amount of direct supervision in their training programs to be a significant factor in valuing their program and thinking highly of the educational experience [26,27]. Supervision Policy We developed a department-wide supervision policy for all of the outpatient behavioral health clinics at our universityaffiliated city hospital (the full policy is available from the authors on request). The policy requires that supervisors and trainees meet weekly for oversight supervision and that if either party is unable to meet, the supervisor determines if there is a need to meet before the following week’s supervision. It also states explicitly that supervisors are responsible for all final pharmacological and other psychotherapeutic treatment decisions. Particularly germane to this discussion, our policy identifies specific triggers for direct supervision. For intake evaluations of new patients, attending physician supervisors are required to provide direct supervision so that they can directly assess the patient and the trainee’s assessment of the patient. Initially, faculty are present for the full evaluation, but
Acad Psychiatry
once they determine the fellow is competent to adequately gather and convey mental status and history, they are present for only part of the evaluation so that they can assess mental status and address any of their outstanding questions. Additionally, for patients who have been discharged from the CPEP or from a hospitalization, attending physician supervisors are required to meet face-to-face with the trainee and patient at reentry to outpatient services and provide direct supervision so that care decisions are informed by the attending physician’s participation in the risk assessment and mental status examination. The policy governs supervision in both the adult and the child and adolescent ambulatory psychiatry clinics. There are no significant differences in the policy provisions for supervision of treatment by trainees of adult and child and adolescent psychiatric patients. The new policy defines the methods of supervision exercised as direct, indirect, and oversight (consistent with ACGME definitions). For ongoing cases in child and adolescent psychiatry, we developed a set of triggers for direct supervision. These include (1) patients who had been discharged from the CPEP or the inpatient psychiatry service; (2) periodic direct supervision on ongoing continuity cases; (3) when after feedback from the supervisor, the trainee was unable to clearly report findings from the mental status exam or the patient’s history in a way that made clear to the supervisor the patient’s diagnosis and clinical status; (4) when there was an elevation of risk status that did not respond to those interventions discussed during oversight or indirect supervision and implemented by the trainee; (5) to resolve conflicts or concerns raised by patients, parents, or guardians between the patient, parent, or guardian and the trainee that cannot be resolved by the trainee after indirect or oversight supervision. After we developed our guidelines, they were reviewed and accepted by our hospital administration as policy. Additionally, they were reviewed with fellows at the weekly fellows’ meeting and with the clinic’s teaching staff at the biweekly administrative meeting. They have been also incorporated into the child and adolescent psychiatry fellowship handbook.
Discussion One of our trainees and his supervising attending physician treated a patient who had an untoward outcome. We identified our supervision policy as a possible contributor. This led us to review our supervision policy and the extant literature on direct, indirect, and oversight supervision. After conducting a systematic review of the literature on direct and indirect supervision in psychiatric and other graduate medical education, we determined that the term direct
supervision was relatively new in psychiatry, and there was little published on the impact of direct supervision on the educational experience of psychiatry trainees or trainees in other medical specialties. One study found greater agreement when both the supervisor and resident observed the interview, and two other studies found that patient outcomes were better when residents were directly supervised. In other areas of medicine, several studies indicated that direct supervision has been associated with both improved educational and patient outcomes. We revised our supervision policy to increase direct supervision, especially as part of initial assessment and in higherrisk situations as part of ongoing treatment. We elected to identify specific situations that would require direct supervision but did not make direct supervision a requirement for all clinical encounters. We now require direct supervision for all new evaluations whereby the attending physician is present to directly assess the patient and the trainee’s assessment of the patient. Initially, faculty is present for the full evaluation but once the faculty member determines the fellow is competent to adequately gather and convey mental status and history, the faculty is present for only part of the evaluation in order to assess mental status and address any outstanding questions. We also identified specific (higher-risk) situations in ongoing care that would trigger an attending physician to provide direct supervision. These triggers take into account individual trainees’ skills and patient risk factors. These policies were sustainable for our program, and we encourage other programs to assess whether they may be right for their programs. The data are limited, but these positive studies raise the question of why there is no greater implementation of direct supervision in psychiatry training programs. Our review led us to believe that several factors contributed to limited widespread implementation of direct supervision including following the status quo, which in psychiatry was oversight supervision and had been perceived as being effective in most situations, the desire to foster trainee’s autonomy, to preserve the perception of confidentiality, limited guidelines and regulations regarding direct supervision. Additionally, ACGME addresses the transition of supervision in the first to second year of training; however, transitions later in training are not addressed. Our literature search using direct and indirect supervision did not identify articles on the impact of regulatory and fiscal realities on supervision, yet they may also impact on supervision policy. Individual supervision time is among the largest personnel-related expenses for training programs [28]. Teaching hospitals receive reimbursement for “direct costs” they incur in training physicians: salaries, teaching, supervision, and overhead. The Medicare program reimburses teaching hospitals for a portion of these expenses through direct graduate medical education (DGME) payments.
Acad Psychiatry
Medicare does not make GME payments for outpatient services, but it may reimburse for outpatient services provided by trainees. Certain states and insurance policies require the attending physician’s presence in the room with the patient in order to reimburse for service. Other states, including New York, follow Medicare rules when using Medicaid funds to pay for outpatient services furnished by residents and allow payment for outpatient care furnished by residents without the physical presence of the attending physician [29]. The Center for Medicare & Medicaid Services (CMS) recently decided to reduce its supervision requirement from direct to oversight as a concession to small rural hospitals with difficulty meeting the staffing needed to be compliant with a direct supervision requirement [30]. CMS’s actions raised concern in the American Psychiatric Association that the new supervision standards were “too lax” to ensure delivery of safe and effective care [31]. Current GME payment structure is blind to the type or amount of supervision an individual resident needs or receives. The payment rates for subspecialty training assume that advanced trainees would need and utilize less training resources. Hence, at most institutions, there is inherent tension between faculty time allocated for direct care and trainee supervision, as one is seen as revenue generating and the other is not. Wider use of direct supervision in psychiatry training has the potential to ease some of this tension. Further investigation is needed to determine direct supervision if a higher fee-for-service reimbursement for directly supervised patient encounters would result in higher patient satisfaction, better retention in treatment, and fewer adverse treatment events. Additionally, whether these more intangible outcomes would offset lost revenue from unrealized faculty direct care encounters needs further study. Our change in policy was not designed to measure if guidelines on direct supervision improved patient care and the trainee’s educational experience. Further research is needed in order to examine the impact of different types of supervision on trainee education and patient outcomes. In our experience, the implementation of our policy has added an average of 1 hour of direct supervision per faculty member per week to the 1 hour of oversight supervision per trainee expected as minimum supervision effort. This hour is at the expense of individual faculty member productivity. We recognize that financial and workforce realities may vary with each institution, limiting the ability to extend direct supervision resource. We strongly believe that the potential gains in educational outcomes, patient safety, and patient satisfaction make the consideration of a direct supervision policy worthwhile. The financial impact of implementing direct supervision, finding ways to measure the indirect benefits (including financial) of direct supervision in psychiatry, and the most efficient ways to dose and deliver direct supervision merits further study.
Our experience raised for us the question of whether more specific guidelines from the ACGME on when direct supervision should be required would improve resident education and patient care. The new ACGME milestones for general psychiatry include anchors that describe increasing skill levels [32, 33]. These anchors are not tied back to progressive authority. The field would benefit from further research and guidance on the level of training (based on years, skills, and milestone levels) and clinical situations where direct supervision is required and whether where more advanced residents and patients would benefit from further autonomy. Similarly, we would benefit from research evaluating whether these new milestones are valid and effective in assessing trainee skill and readiness for progression. Potential negative impact on trainees developing more independence and autonomy needs further study. Given the limited guidelines from the ACGME, the implementation of direct supervision in outpatient psychiatry is left to the discretion of the training program and likely varies. There are also limited data on how often and in what circumstances direct supervision is used in both general and child and adolescent psychiatry training programs, both historically and currently. This, too, needs further study. Acknowledgments The authors gratefully acknowledge Sabina Singh, M.D. for her contribution in developing our supervision policy and Barbara Gamboni-Silva for her administrative assistance in preparing this manuscript. Disclosures Drs. Green, Merlino, Naidoo, and Nikolov have nothing to disclose. Dr. Galanter receives royalties from American Psychiatric Publishing, Inc. and is on the scientific steering committee of the REsource for Advancing Children’s Health (REACH) Institute.
References 1. Common Program Requirements, Effective July 1 2011. http:// acgme-2010standards.org/pdf/Common_Program_Requirements_ 07012011.pdf. Accessed 6/4/2013. 2. Watkins CE. Psychotherapy supervision in the 21st century. J Psychother Pract Res. 1998;7:93–101. 3. Yogev S. An eclectic model of supervision: a developmental sequence for beginning psychotherapy students. Prof Psychol. 1982; 13:2. 4. Baudry FD. The personal dimension and management of the supervisory situation with a special note on the parallel process. Psychoanal Q. 1993;62:588–614. 5. Kernberg OF. Psychoanalytic supervison: the supervisor’s tasks. Psychoanal Q. 2010;79:603–27. 6. ACGME. Graduate medical education directory 2003–2004. Chicago: AMA Press; 2003. 7. Ulmer C, Wolman DM, Johns MME. In: Resident Duty Hours: Enhancing Sleep, Supervision and Safety (IOM 2009) Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, editors. National Research Council. 8. ACGME Review Committee for Psychiatry. ACGME Program requirements for Graduate Medical Education in Psychiatry, https://
Acad Psychiatry
9.
10. 11. 12.
13.
14.
15.
16.
17. 18.
19.
20.
w w w. a c g m e . o r g / a c g m e w e b / P o r t a l s / 0 / P FA s s e t s / ProgramRequirements/400_psychiatry_07012007_u04122008. pdf(2011). Reviewed 12 June 2014. ACGME Review Committee for Psychiatry. ACGME Program requirements for Graduate Medical Education in Child and Adolescent Psychiatry, (http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ ProgramRequirements/405pr07012007.pdf) (2011). Reviewed 6 May 2013. Stein SP, Karasu TB, Charles ES, Buckley PJ. Supervision of the Initial Interview. Arch Gen Psychiatry. 1975;32:265–8. Kass F, et.al. Assessing the impact of supervision on outpatient evaluation in psychiatry, QRB. 1984; 3–5. Jaynes S, Charles E, Kass F, Holzman F. Clinical supervision of the initial interview: effects on patient care. Am J Psychiatry. 1979;136: 1454–7. Krasner RF, Shelby SR, Howard KI. Are advanced psychiatry residents more skillful than beginning residents in the conduct of psychodynamic psychotherapy. Acad Psychiatry. 1999;23:88–94. Weerasekera P, Antony MM, Bellissimo A, Bieling P, Shurina-Egan J, Spencer A, et al. Competency assessment in the McMaster psychotherapy program. Acad Psychiatry. 2003;27:166–73. Sudak DM, Goldberg DA. Trends in psychotherapy training: a national survey of psychiatry residency training. Acad Psychiatry. 2013;36:369–73. Szeftel R, Hakak R, Meyer S, Naqvi S, Sulman-Smith H, Delrahim K, et al. Training psychiatric residents and fellows in a telepsychiatry clinic: a supervision model. Acad Psychiatry. 2008;32:393–9. Mellsop GW, MacDonald J, El Badri S, Menkes D. Patients’ appraisal of psychiatric trainee interview skills. Acad Psychiatry:. 2012;36:374–9. Ravitz P, Lancee WJ, Lawson A, Maunder R, Hunter JJ, Leszcz M, et al. Improving physician–patient communication through coaching of simulated encounters. Acad Psychiatry. 2013;37:87–93. Young JQ, Lieu S, O’Sullivan P, Tong L. Development and initial testing of a structured clinical observation tool to assess pharmacotherapy competence. Acad Psychiatry. 2011;35:27–34. Farnan JM, Petty LA, Georgitis E, Martin S, Chiu E, Prochaska M, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87(4):428–42.
21. Durham R, Shapiro D, Flint L. In-house trauma attendings: is there a difference? Am J Surg. 2005;190:960–6. 22. Claridge JA, Carter JW, McCoy AM, Malangoni MA. In-house direct supervision by an attending is associated with differences in the care of patients with a blunt splenic injury. Surgery. 2011;150:718–26. 23. Sox CM, Burstin HR, Orav EJ, Conn A, Setnik G, Rucker DW, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998;73(7):776–82. 24. de Oliveira Filho GR, Dexter F. Interpretation of the association between frequency of self-reported medical errors and faculty supervision of anesthesiology residents. Anesth Analg. 2013;116:752–3. 25. Demarest GB, Scannell G, Sanchez K, Dziwulski A, Qualls C, Schermer CR, et al. In -house versus on-call attending trauma surgeons at comparable level I trauma centers: a prospective study. J Trauma. 1999;46:535–40. 26. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005;16:2607–13. 27. Lascano CA, Stovak ML, Harvey AT. Direct versus indirect supervision of fellows covering football events: a survey of fellows and program directors. J Grad Med Educ. 2010;2:442–8. 28. Magen J, Banazac D. The cost of residency training in psychiatry. Acad Psychiatry. 2000;24:195–201. 29. DHHS/CMC. Guidelines for Teaching Physicians, Interns, and Residents, Fact Sheet. 2011. http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNProducts/ downloads/gdelinesteachgresfctsht.pdf. Accessed 4/9/2013. 30. Centers for Medicare and Medicaid Services. CMS’ final decisions on the recommendations of the hospital outpatient payment panel on supervision levels for select services, (May 22 2012), retrieved May 23, 2013, website: www.cms.gov/Regulations-and-Guidance/ Guidance/FACA/Downloads/PrelimSupervisionDecisions.pdf. 31. Wolfe J. “Outpatient supervision standards too lax, APA tells CMS,” Psychiatr News, 2012; 9. 32. Thomas CR. Educational milestone development for psychiatry. J Grad Med Educ. 2014;6(1s1):281–3. 33. The Psychiatry Milestone Project. J Grad Med Educ. 2014; 6 1s1: 284–304.
