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Oversight, ownership, and the development of expertise

Part 4: The team as an oversight tool

In much the same way that your clinical team can help you care for patients, they can serve as a resource to help you achieve the supervisory sweet spot with learners. 

In part 3, we talked about setting ownership expectations with learners at the beginning of the shift. Maybe you decided that the resident was going to take full ownership of the ED course, but does the rest of your team know that? Nurses, techs, and other clinical staff play an important role in resident training, and their actions can support or undermine the resident training experience.
After you’ve set expectations for ownership with your learner, let nurses and techs know what to expect, too. Include details about ownership, such as whom to approach when there are changes to the clinical course, requests for medications, or questions about ED management. Chances are you’ll still be asked to make some clinical decisions, even when you’ve designated the resident as the go-to person. No problem! Just let him or her know of any changes you made or orders you placed. It’s important for the resident to understand how the clinical course unfolded--and it reduces the possibility of error due to duplication of efforts.
Incorporate your team into your oversight plans as well and let them know that despite allowing the resident to practice clinical decision-making, you want to be aware of and involved in patient care, not to mention always available for their concerns. You can extend your oversight by using other members of your team as additional eyes and ears. Nurses and techs have a lot to offer in terms of feedback for residents, including but not limited to communication skills and ED processes. Especially when it aligns with their on-shift goals, this kind of feedback can be very helpful for residents. Use it to your advantage!
Your team obviously may include PGY3 and 4 EM residents who, in addition to taking ownership of their own patients and zone, may have an oversight responsibility as well. If they’re providing supervision, you’ll need to orient the more senior resident to the level of ownership you would like the more junior resident to demonstrate and the nature of the oversight you’d like them to provide. 

One technique we really like is redirecting questions from nursing staff to the resident but including expected or acceptable responses: “Please ask Dr. Jones what she would like to do so she knows what is going on. Because of the patient’s long QT and several previous medications, I would expect her to choose a medication that doesn't prolong the QT--like lorazepam.”
By redirecting the nurse to the learner, you allow the resident to practice clinical decision-making. Using the nurse to provide feedback on her recommendation creates oversight of the decision-making and helps the resident improve her practice. 

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Biondi EA, Varade WS, Garfunkel LC, et al. Discordance Between Resident and Faculty Perceptions of Resident Autonomy. Academic Medicine 2015;90(4):462–71.

Ericsson KA. (2016). Peak: Secrets from the New Science of Expertise. Boston : Houghton Mifflin Harcourt.

Ericsson KA. (2004). Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Academic Medicine, 79(10), S70–S81.

Ericsson KA, Krampe RT,  Tesch-Römer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363–406.

Ericsson, KA. (2009). Development of professional expertise: toward measurement of expert performance and design of optimal learning environments. New York, Cambridge University Press. 

Gladwell, M. (2008). Outliers: The story of success.

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