Commentary: watching closely at a distance: key tensions in supervising resident physicians

Graded responsibility and autonomy are integral features of medical education. High-quality patient care is paramount and is the ultimate responsibility of the attending physician. In the training setting, the teaching attending holds quality of care constant while balancing the amount of supervision and autonomy he or she gives the learner. Sterkenburg and colleagues focus on how faculty members make their decisions to entrust patient care to learners. Both this critical decision and the process of deciding, performed many times a day by teaching faculty, are at the heart of the confluence of providing quality patient care and developing the next generation of physicians. Sterkenburg and colleagues innovatively use a system of rating (with six sequentially more complex entrustable professional activities [EPAs]) and structured interviews to better understand the current practice of entrusting care. They defined gaps between when attending faculty feel residents are ready to perform a particular EPA, when the residents feel ready, and when the residents actually perform it. The tension between the imperative to ensure quality care and the competing imperative to grant graded autonomy can be described as "watching closely at a distance." The details of who should watch whom, when and what to watch, and how and how much to watch are all key issues for faculty and residents. Sterkenburg and colleagues provide a framework for further investigation (e.g., discerning the ideal level of supervision, developing a gold standard for assessing EPAs) into these critical medical education challenges.