Attending Supervision

The July 1989 Section 405 of the New York State Code of Rules and Regulations, governing residents in training, mandates immediate attending supervision of all aspects of non-operative, pre-operative, opera¬tive and post-operative care of patients. In compliance with the law, each patient has an assigned attend¬ing surgeon, who is responsible for both medical, social, ethical and legal aspects of the patient's care,

The attending surgeons provide supervision through the chief resident who assumes the major responsibil¬ity for the care of patients on a particular service to which he/she is assigned. From the junior resident through the senior and chief resident, there is graded authority and increasing responsibility. This increas¬ing responsibility is given to residents after direct observation of increasing skill, ability, cognitive knowl¬edge and evaluations based on the general competencies.

The attending surgeon supervises in-patient care through patient examination and discussion with the resi¬dent for both admissions and consultations. Supervision is documented by appropriate notes in the chart, indicating that the resident's findings and care have been reviewed and agreed upon.

Attending surgeons attend out-patient clinics. Residents take a detailed history, examine the patient, and consult with the attending surgeons to confirm the diagnosis and to develop a management plan (pre¬operative work-up, operative care, post-operative care and follow-up.) The attending surgeons and resident staff take into consideration the ethical, economical, legal and social aspects of patient care as the man¬agement plans are developed and implemented.

Attending surgeons are present in the operating room to assist, guide and educate the resident in opera¬tive procedures. The attending surgeon is in the operating room whenever an operation is performed. At¬tending surgeons make ward rounds with residents and attend Grand Rounds for the discussion of morbid¬ity and mortality as well as selected cases of interest. The surgical attending encourages and stimulates aca¬demic discussion including review of the literature to support patient management and introduction and evaluation of advances in surgery.

Attending surgeon supervision encourages the progressive independent decision making of residents, so that the resident achieves independence by the end of the chief residency.

Attending surgeons and section chiefs are responsible for the evaluation of the resident's performance. Monthly evaluation is prepared for each resident.

Attending surgeons discuss with residents the concepts of Managed Care, billing, cost containment, medico-legal issues, ethical issues, and the importance of Joint Commission, quality assurance and other aspects of the man¬agement of a surgical practice in a hospital.

The levels of supervision are direct, indirect or oversight.

Direct supervision is where the attending is physically present with the resident and the patient. This is most encouraged. Attendings are always in house in the day time on weekdays. During on call period, on weekends and holidays, there is always an attending on call in house and can be called to evaluate patients with residents immediately.

Indirect supervision can occur where the attending is not physically present but is readily available by telephone and/or electronic means to provide direct supervision. All attendings can be reached this way.

Oversight supervision is where the attending is available to provide review of procedure/encounter with feedback after the care is delivered.