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The Accreditation Council for Graduate Medical Education (ACGME) requires supervision of residents “provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth.”1 Beyond delineating supervision types (direct, indirect, or oversight), best practices for outpatient supervision are lacking, which perhaps contributes to challenges and discrepancies in experiences involving both trainees and supervisors.2 In this article, I provide 6 practical recommendations for supervisors to address and overcome these challenges.
1. Don’t skip orientation
Resist the pressure to jump directly into clinical care. Devote the first supervision session to learner orientation about expectations (eg, documentation and between-visit patient outreach), logistics (eg, electronic health record or absences), clinic workflow and processes (eg, no-shows or referrals), and team members. Provide this verbally and in writing; the former fosters additional discussion and prompts questions, while the latter serves as a useful reference.
2. Plan for the end at the beginning
Plan ahead for end-of-rotation issues (eg, transfers of care or clinician sign-out), particularly because handoffs are known patient safety risks.3 Provide a written sign-out template or example, set a deadline for the first draft, and ensure known verbal sign-out occurs to both you and any trainees coming into the rotation.
3. Facilitate self-identification of strengths, weaknesses, and goals
Individual learning plans (ILPs) are a fundamental component of adult learning theory, allowing for self-directed learning and ongoing assessment by trainee and supervisor. Complete the ILP together at the beginning of the rotation and regularly devote time to revisit and revise it. This process ensures targeted feedback, which will reduce the stress and potential surprises often associated with end-of-rotation evaluations.
4. Consider the homework you assign
Be intentional about assigned readings. Consider their frequency and length, highlight where you want learners to focus, provide self-reflection questions/prompts, and take time to discuss during supervision. If you use a structured curriculum, maintain flexibility so your trainees’ interests, topics arising in real-time clinical care, and relevant in-press articles can be included.
5. Use direct observation
Whenever possible, directly observe clinical care, particularly a patient’s intake. To reduce trainee (and patient) anxiety and preserve independence, state, “I’m the attending physician supervising Dr. (NAME), who will be your doctor. We provide feedback to trainees right up to graduation so I’m here to observe and will be quiet in the background.” While direct observation is associated with early learners and inpatient settings, it is also preferred by senior outpatient psychiatry residents4 and associated with positive educational and patient outcomes.5
6. Offer supplemental experiences
If feasible, offer additional interdisciplinary supervision (eg, social workers, psychologists, or peer support), scholarly opportunities (eg, case report collaboration or clinic talk), psychotherapy cases, or meeting with patients on your caseload (eg, patients with a rare diagnosis or unique presentation). These align with ACGME’s broad supervision requirements and offer much-appreciated individualized learning tailored to the trainee.
1. Accreditation Council for Graduate Medical Education. Common Program Requirements (Residency). Updated July 1, 2022. Accessed September 6, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf
2. Newman M, Ravindranath D, Figueroa S, et al. Perceptions of supervision in an outpatient psychiatry clinic. Acad Psychiatry. 2016;40(1):153-156. doi:10.1007/s40596-014-0191-y
3. The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. Issue 58. September 12, 2017. Accessed September 11, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf
4. Tan LL, Kam CJW. How psychiatry residents perceive clinical teaching effectiveness with or without direct supervision. The Asia-Pacific Scholar. 2020;5(2):14-21.
5. Galanter CA, Nikolov R, Green N, et al. Direct supervision in outpatient psychiatric graduate medical education. Acad Psychiatry. 2016;40(1):157-163. doi:10.1007/s40596-014-0247-z
The Accreditation Council for Graduate Medical Education (ACGME) requires supervision of residents “provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth.”1 Beyond delineating supervision types (direct, indirect, or oversight), best practices for outpatient supervision are lacking, which perhaps contributes to challenges and discrepancies in experiences involving both trainees and supervisors.2 In this article, I provide 6 practical recommendations for supervisors to address and overcome these challenges.
1. Don’t skip orientation
Resist the pressure to jump directly into clinical care. Devote the first supervision session to learner orientation about expectations (eg, documentation and between-visit patient outreach), logistics (eg, electronic health record or absences), clinic workflow and processes (eg, no-shows or referrals), and team members. Provide this verbally and in writing; the former fosters additional discussion and prompts questions, while the latter serves as a useful reference.
2. Plan for the end at the beginning
Plan ahead for end-of-rotation issues (eg, transfers of care or clinician sign-out), particularly because handoffs are known patient safety risks.3 Provide a written sign-out template or example, set a deadline for the first draft, and ensure known verbal sign-out occurs to both you and any trainees coming into the rotation.
3. Facilitate self-identification of strengths, weaknesses, and goals
Individual learning plans (ILPs) are a fundamental component of adult learning theory, allowing for self-directed learning and ongoing assessment by trainee and supervisor. Complete the ILP together at the beginning of the rotation and regularly devote time to revisit and revise it. This process ensures targeted feedback, which will reduce the stress and potential surprises often associated with end-of-rotation evaluations.
4. Consider the homework you assign
Be intentional about assigned readings. Consider their frequency and length, highlight where you want learners to focus, provide self-reflection questions/prompts, and take time to discuss during supervision. If you use a structured curriculum, maintain flexibility so your trainees’ interests, topics arising in real-time clinical care, and relevant in-press articles can be included.
5. Use direct observation
Whenever possible, directly observe clinical care, particularly a patient’s intake. To reduce trainee (and patient) anxiety and preserve independence, state, “I’m the attending physician supervising Dr. (NAME), who will be your doctor. We provide feedback to trainees right up to graduation so I’m here to observe and will be quiet in the background.” While direct observation is associated with early learners and inpatient settings, it is also preferred by senior outpatient psychiatry residents4 and associated with positive educational and patient outcomes.5
6. Offer supplemental experiences
If feasible, offer additional interdisciplinary supervision (eg, social workers, psychologists, or peer support), scholarly opportunities (eg, case report collaboration or clinic talk), psychotherapy cases, or meeting with patients on your caseload (eg, patients with a rare diagnosis or unique presentation). These align with ACGME’s broad supervision requirements and offer much-appreciated individualized learning tailored to the trainee.
The Accreditation Council for Graduate Medical Education (ACGME) requires supervision of residents “provides safe and effective care to patients; ensures each resident’s development of the skills, knowledge, and attitudes required to enter the unsupervised practice of medicine; and establishes a foundation for continued professional growth.”1 Beyond delineating supervision types (direct, indirect, or oversight), best practices for outpatient supervision are lacking, which perhaps contributes to challenges and discrepancies in experiences involving both trainees and supervisors.2 In this article, I provide 6 practical recommendations for supervisors to address and overcome these challenges.
1. Don’t skip orientation
Resist the pressure to jump directly into clinical care. Devote the first supervision session to learner orientation about expectations (eg, documentation and between-visit patient outreach), logistics (eg, electronic health record or absences), clinic workflow and processes (eg, no-shows or referrals), and team members. Provide this verbally and in writing; the former fosters additional discussion and prompts questions, while the latter serves as a useful reference.
2. Plan for the end at the beginning
Plan ahead for end-of-rotation issues (eg, transfers of care or clinician sign-out), particularly because handoffs are known patient safety risks.3 Provide a written sign-out template or example, set a deadline for the first draft, and ensure known verbal sign-out occurs to both you and any trainees coming into the rotation.
3. Facilitate self-identification of strengths, weaknesses, and goals
Individual learning plans (ILPs) are a fundamental component of adult learning theory, allowing for self-directed learning and ongoing assessment by trainee and supervisor. Complete the ILP together at the beginning of the rotation and regularly devote time to revisit and revise it. This process ensures targeted feedback, which will reduce the stress and potential surprises often associated with end-of-rotation evaluations.
4. Consider the homework you assign
Be intentional about assigned readings. Consider their frequency and length, highlight where you want learners to focus, provide self-reflection questions/prompts, and take time to discuss during supervision. If you use a structured curriculum, maintain flexibility so your trainees’ interests, topics arising in real-time clinical care, and relevant in-press articles can be included.
5. Use direct observation
Whenever possible, directly observe clinical care, particularly a patient’s intake. To reduce trainee (and patient) anxiety and preserve independence, state, “I’m the attending physician supervising Dr. (NAME), who will be your doctor. We provide feedback to trainees right up to graduation so I’m here to observe and will be quiet in the background.” While direct observation is associated with early learners and inpatient settings, it is also preferred by senior outpatient psychiatry residents4 and associated with positive educational and patient outcomes.5
6. Offer supplemental experiences
If feasible, offer additional interdisciplinary supervision (eg, social workers, psychologists, or peer support), scholarly opportunities (eg, case report collaboration or clinic talk), psychotherapy cases, or meeting with patients on your caseload (eg, patients with a rare diagnosis or unique presentation). These align with ACGME’s broad supervision requirements and offer much-appreciated individualized learning tailored to the trainee.
1. Accreditation Council for Graduate Medical Education. Common Program Requirements (Residency). Updated July 1, 2022. Accessed September 6, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf
2. Newman M, Ravindranath D, Figueroa S, et al. Perceptions of supervision in an outpatient psychiatry clinic. Acad Psychiatry. 2016;40(1):153-156. doi:10.1007/s40596-014-0191-y
3. The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. Issue 58. September 12, 2017. Accessed September 11, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf
4. Tan LL, Kam CJW. How psychiatry residents perceive clinical teaching effectiveness with or without direct supervision. The Asia-Pacific Scholar. 2020;5(2):14-21.
5. Galanter CA, Nikolov R, Green N, et al. Direct supervision in outpatient psychiatric graduate medical education. Acad Psychiatry. 2016;40(1):157-163. doi:10.1007/s40596-014-0247-z
1. Accreditation Council for Graduate Medical Education. Common Program Requirements (Residency). Updated July 1, 2022. Accessed September 6, 2023. https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf
2. Newman M, Ravindranath D, Figueroa S, et al. Perceptions of supervision in an outpatient psychiatry clinic. Acad Psychiatry. 2016;40(1):153-156. doi:10.1007/s40596-014-0191-y
3. The Joint Commission. Inadequate hand-off communication. Sentinel Event Alert. Issue 58. September 12, 2017. Accessed September 11, 2023. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_58_hand_off_comms_9_6_17_final_(1).pdf
4. Tan LL, Kam CJW. How psychiatry residents perceive clinical teaching effectiveness with or without direct supervision. The Asia-Pacific Scholar. 2020;5(2):14-21.
5. Galanter CA, Nikolov R, Green N, et al. Direct supervision in outpatient psychiatric graduate medical education. Acad Psychiatry. 2016;40(1):157-163. doi:10.1007/s40596-014-0247-z
