You Can't Start a Central Line? Supervising Residents at Different Stages of the Learning Cycle.

You are an attending physician in the medical intensive care unit and receive a call from the charge nurse. She tells you that the senior resident has been unable to place the central line that was discussed on rounds. You call the resident to get more information. The resident tells you that he has had multiple opportunities to place a central line with limited success. You are particularly stunned, not only because you assume that every postgraduate year 3 resident should be able to place a central line without direct supervision, but also because this resident has demonstrated outstanding knowledge of pulmonary physiology and ventilator management. With this realization, what are the implications for your program’s teaching and supervision paradigms? The Accreditation Council for Graduate Medical Education (ACGME) Common Program Requirements place significant emphasis on supervision of residents and codify the levels of supervision, 1 yet offer little guidance on identification of the level of supervision for any particular task or skill. Many program leaders have expressed frustration when attempting to construct a conceptual model for supervision in the context of progressive responsibility. In this perspective, we review several models of learning and skill development: the Hersey-Blanchard Situational Leadership model, 2 the Stages of Competence model, 3 the RIME model, 4 and the Dreyfus model. 5 We demonstrate that these models provide a structured framework for conceptualizing supervision of residents at various stages in their development, which parallel the ACGME concept of progressive responsibility. Our aim is to provide readers with models to help guide the design of a supervision structure for their programs that both categorizes residents at each level of supervision and operationalizes that supervision for faculty.