The concept of graduated responsibility has been a firm commitment and characteristic of this educational program from its inception. This is realized through two parallel approaches, one structural and the other based upon individual assessment. The structural considerations include both the personnel on the specific rotations and the service-specific responsibilities as well as the nature of the institutions in which they occur. For example, most in-patient services are staffed by both junior and senior residents. The junior residents are charged with “running the floor” under the direct supervision of their senior resident or the attending, depending upon the nature of the service. Senior residents are responsible for advanced decision making related to the care of patients, supervising junior residents in this activity and being responsible to specific attendings.
In the out-patient setting, most resident clinics at each institution are staffed by both a junior and senior resident and always by an attending orthopaedic surgeon. In these clinics, juniors work directly with senior residents who have the supervisional responsibility of junior residents and medical students. Both residents ultimately are under the supervision of attending staff, with the intensity of supervision reflecting the skill of the residents assigned. Other subspecialty clinics staffed by full-time faculty usually require assigned house staff to evaluate new patients prior to being seen by the attending. Then these patients are presented along with a differential diagnosis, further work-up strategy, and outline of treatment alternatives. For follow-up patients, an assessment of progress and any modification in rehabilitation programs are provided by residents to attendings.
Increasing responsibility in the operating room reflects the structure of having a junior, senior and attending all present for most cases. When the junior resident plays a primary role, then the senior resident is responsible for assisting in a teaching capacity. When the senior, by virtue of case complexity, is the primary surgeon (under the direction of the attending) then the junior resident is responsible for assisting, understanding the case, and learning from this experience. There are also many cases in which the junior or senior is scrubbed alone with the attending for a case. In this setting, the resident has an opportunity for one-on-one teaching with the attending.
The emergency room provides a very effective structure for increasing responsibility under appropriate supervision. At Yale-New Haven Hospital, for example, the typical on-call team includes a PGY-1 or PGY-2 assigned to the wards, but expected to accompany the PGY-3 or PGY-4 to the ER when schedules permit. The PGY-3 or the PGY- 4 is responsible for the ER and reports to and is directly supervised by the chief resident, who is required to participate in any ER care requiring an operative procedure and to respond to ER consultations beyond the experience or comfort level of the junior members of the team. The assigned attending is always primarily responsible for the care delivered by any resident in the ER.
In summary, the structure of resident assignments on specific services and the explicit nature of responsibilities on these rotations ensure that all residents receive appropriate supervision, but experience increasing levels of responsibility for patient care.
The second major mechanism for adjusting responsibility to capabilities is through the assessment of resident skills by attending and chief resident physicians. The department maintains a commitment to provide an environment for individual growth based upon experience as well as emphasizing maximum safe assumption of responsibilities at the earliest possible time based upon skill. Resident evaluations every six months by the faculty insure that residents in need of enhanced support receive this assistance in a timely fashion and that those capable are given commensurate and increasing levels of responsibility.