Enhancing Mentorship in Medicine with Malpractice Data

When a post-surgery patient was discharged to a rehab facility, the surgical resident failed to include the prophylactic anticoagulant medication—ordered by the orthopedic surgeon—on the discharge medication list. Unfortunately, the mistake went unnoticed by the attending and subsequent physicians. As a result, the patient never received the medication during her stay at the rehab facility, leading to a tragic and preventable fatal pulmonary embolism.

As a new cohort of residents embark on their medical journey on July 1, we reflect on malpractice risks associated with supervising residents and fellows, known as house staff. Of almost 31,000 medical professional liability (MPL) cases that closed between 2018 and 2022 in the Candello database, 539 (1.8%) involved house staff supervision issues. While Candello data indicate such cases are relatively infrequent, understanding these trends can equip supervising physicians and health care organizations with the tools needed to adequately support new physicians in delivering safe and high-quality care.

As depicted below, cases involving house staff supervision tend to involve severe patient injury or death and result in higher financial losses. The top co-occurring contributing factors also shed light on how issues related to trainee supervision can have a domino effect on other aspects of patient care.

Long-time surgeon, educator, and researcher focusing on resident and faculty education and patient safety, Douglas Smink, MD, MPH, at Brigham & Women’s Hospital and Brigham & Women’s Faulkner Hospital, emphasizes the importance of supervised practice for resident doctors. He says, “Supervision of house staff is crucial, as it prioritizes patient safety and safeguards against medical errors while fostering a culture of learning and continual improvement. Structured supervision enables residents and fellows to translate their knowledge into safe patient care.”

Although cases are infrequent, the severity of an event involving house staff and the average indemnity payment is significantly greater than cases without this factor. Considering different medical specialties have varying training methods, below are some general recommendations for supervising physicians and health care administrators to best support new physicians in caring for patients.

Recommendations for Attending Physicians

• Establish clear communication. Provide guidelines for when residents should contact attending physicians, especially during critical events such as ICU transfers and cardiac arrests. Giving trainees pocket reminder cards that list examples of when to reach out has proven effective.
  
  
• Promote teamwork. Foster an environment where trainees can learn from mistakes and receive support during adverse events. This includes offering formal support systems and educating trainees about malpractice risks in various specialties.
  
  
• Provide regular, constructive feedback. Help trainees improve and build confidence.
  
  
• Encourage openness. Be approachable and reassure residents and fellows that seeking advice is not a sign of weakness.

Recommendations for Health Care Organizations

• Create and enforce clear policies. Establish defined chains of command.
  
  
• Enhance communication. Implement tools, like reminder cards, for critical event notifications.
  
  
• Support trainees. Provide formal support systems for those involved in adverse events and educate them on the malpractice risks associated with different specialties.

According to the Association of American Medical Colleges 2023 Report on Residents, the number of residents has increased by 5,000 yearly since 2019, reaching almost 154,000 active residents in 2023. However, the physician shortage still grips the nation and threatens to grow as more physicians leave the industry. This juxtaposition in the health care workforce may affect the time attendings have to spend supervising their residents, making it even more critical for organizations to formally structure their house staff supervision.

This will help ensure that new cohorts of doctors receive the supervision/training needed to practice safe and quality medicine confidently throughout their medical careers.