Independence vs oversight

Potential malpractice liability is one of many factors that postgraduate psychiatry programs consider when titrating the amount and intensity of supervision against letting residents make independent decisions and take on clinical responsibility for patients. Patients deserve good care and protection from mistakes that inexperienced physicians may make. At the same time, society recognizes that educating future physicians requires allowing residents to get real-world experiences in evaluating and treating patients.

These ideas are expressed in the “Program Requirements” for psychiatry residencies promulgated by the Accreditation Council for Graduate Medical Education (ACGME).¹⁵ According to the ACGME, the “essential learning activity” that teaches physicians how to provide medical care is “interaction with patients under the guidance and supervision of faculty members” who let residents “exercise those skills with greater independence.”¹⁵

Psychiatry residencies must fashion learning experiences and supervisory schemes that give residents “graded and progressive responsibility” for providing care. Although each patient should have “an identifiable, appropriately-credentialed and privileged attending physician,” residents may provide substantial services under various levels of supervision described in Table 2.¹⁶

Deciding when and what kinds of patient care may be delegated to residents is the responsibility of residency program directors, who should base their judgments on explicit, prespecified criteria using information provided by supervising faculty members. Before letting first-year residents see patients on their own, psychiatry programs must determine that the residents can:

• take a history accurately

• do emergency psychiatric assessments

• present findings and data accurately to supervisors.

Physicians at all levels need to recognize when they should ask for help. The most important ACGME criterion for allowing a psychiatry resident to work under less stringent supervision is that the resident has demonstrated an “ability and willingness to ask for help when indicated.”¹⁶

Getting specifics

One way to respond Dr. R’s questions is to ask, “Do you know when you need help, and will you ask for it?” But her concerns deserve a more detailed (and more thoughtful) response that inquires about details of her training program and its specific educational experiences. Although it would be impossible to list everything to consider, some possible topics include:

• At what level of experience and training do residents assume this coverage responsibility?

• What kind of preparation do residents receive?

• What range of problems and conditions do the patients present?

• What level of clinical support is available on site—eg, experienced psychiatric nurses, other mental health staff, or other medical specialists?

• What has the program’s experience shown about residents’ actual readiness to handle these coverage duties?

• What guidelines have faculty members provided about when to call an attending physician or request a faculty member’s presence? Do these guidelines seem sound, given the above considerations?

Bottom Line

Psychiatry residents have supervisee relationships that create potential vicarious liability for institutions and faculty members. Residency training programs address these concerns by implementing adequate preparation for advanced responsibility, developing evaluative criteria and supervisory guidelines, and making sure that residents will ask for help when they need it.

Related Resources

• Regan JJ, Regan WM. Medical malpractice and respondeat superior. South Med J. 2002;95(5):545-548.
• Winrow B, Winrow AR. Personal protection: vicarious liability as applied to the various business structures. J Midwifery Womens Health. 2008;53(2):146-149.
• Pozgar GD. Legal aspects of health care administration. 11th edition. Sudbury, MA: Jones & Bartlett Learning, LLC; 2012.

Disclosure
Dr. Mossman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Restatement of the law of agency. 3rd ed. §7.07(2). Philadelphia, PA: American Law Institute; 2006.

2. Baty T. Vicarious liability: a short history of the liability of employers, principals, partners, associations and trade-union members. Oxford, England: Clarendon Press; 1916.

3. Dessauer v Memorial General Hosp, 628 P.2d 337 (N.M. 1981).

4. Firestone MH. Agency. In: Sandbar SS, Firestone MH, eds. Legal medicine. 7th ed. Philadelphia, PA: Mosby Elsevier; 2007:43-47.

5. Dobbs D, Keeton RE, Owen DG. Prosser and Keaton on torts. 5th ed. St. Paul, MN: West Publishing Co; 1984.

6. Austin v Litvak, 682 P.2d 41 (Colo. 1984).

7. Kirk v Michael Reese Hospital and Medical Center, 513 N.E.2d 387 (Ill. 1987).

8. Gregg v National Medical Health Care Services, Inc., 499 P.2d 925 (Ariz. App. 1985).

9. Adamski v Tacoma General Hospital, 579 P.2d 970 (Wash. App. 1978).

10. Johnson v LeBonheur Children’s Medical Center, 74 S.W.3d 338 (Tenn. 2002).

11. Reuter SR. Professional liability in postgraduate medical education. Who is liable for resident negligence? J Leg Med. 1994;15(4):485-531.