Risk Management for the Supervising Psychiatrist

The second pitfall is the ineffective monitoring of the welfare of the trainee—and thus his patient—and not knowing when to involve the administrative program director. Many supervisors worry in isolation rather than share concerns with other supervisors to determine whether supervisory problems are systemic. The program director should be notified if the trainee does not report to the supervisor regularly; the trainee does not follow the agreed upon case method; learning is not proceeding at the expected rate; concerns exist about the trainee’s physical or mental health; and unethical behavior exists or there is a question about possible unethical behavior.

The third pitfall results from insufficient guidelines and thus a lack of understanding by trainees about evaluation methods and opportunities for feedback.

The fourth pitfall is caused by a lack of institutional policies regarding dual relationships. Supervision that evolves into friendships or romantic relationships is unethical, and supervisors are duty bound to request a replacement if a dual relationship occurs.

Fault line 2: supervisor and trainee

Supervisors can take 7 steps to ensure ethical and effective supervision (Table 1).¹ The early phase of supervision is the foundation on which a relationship of trust, anxiety reduction, and openness to feedback is established. An alliance between the supervisor and trainee is required and a framework and learning goals are key to a collaborative learning experience that fosters development of the trainee’s critical thinking and decision making.¹⁰

When discussing the framework and goals of the program, the supervisor must be clear about what the expectations are for the trainee and what the evaluation process will entail. Some state laws require supervisors to inform trainees in writing what the evaluation process involves.⁷ It is considered unethical to evaluate the work of a trainee without making sure that the trainee has a clear understanding of the expectations and of the methods for evaluation and trainee feedback. A collaborative learning environment provides opportunities for feedback and ensures that the supervisory alliance shares responsibility for what is learned.^1,11 Trainees learn that they share the ethical responsibilities for their patients’ care: keeping their supervisor abreast of all the activities undertaken with the patient allows the supervisor to provide direction for the highest standards of care.

Limits of confidentiality in supervision must be made clear to trainees at the outset. Supervisors must inform program directors when concerns arise about the learning process or about the physical or mental health of trainees. Supervisors are responsible for the welfare of both the patient and the trainee to the extent that the trainee’s mental or physical health affects the care and safety of the patient.

Effective supervision also requires teaching the importance of self-reflection and self-knowledge to the trainee regarding countertransference, personal dynamics, and emotional vulnerabilities. The early phase of supervision is the best time for all trainees to learn that their personal psychotherapy can enhance self-reflection and add support for difficult emotions that may accompany psychiatric training.¹

While many supervisors struggle with simultaneous roles as teacher, supervisor, overseer of the patient’s care, and evaluator, there is no place for blurring the boundaries into friendships and romantic relationships with trainees. Because of the imbalance of power and experience, and the evaluator role, such relationships are unethical and confusing for trainees.¹² An estimated 5% of supervisors acknowledge having dual relationships with their trainees, and these trainees may be more likely to commit boundary violations with patients.¹³ Because of vicarious liability and the position of authority and the control that a supervisor has over a trainee, supervisors have been held liable for the sexual misconduct of a trainee with a patient.¹⁴

The pitfalls of failing to foster a collaborative supervisory alliance with the trainee include having an undercurrent of secrecy, shame, and anxiety.¹⁵ When trainees are afraid to reveal mistakes, the safety of patients is at risk. Also, collaboration reveals a trainee’s countertransference feelings that may lead to dual relationships with patients and provides a safe place to discuss and understand them and avoid acting on them.¹⁶

Documentation is invaluable in the event of a lawsuit for negligent supervision. All pertinent diagnostic and treatment information must be noted in the patient’s record by the trainee and monitored by the supervisor.⁵ Documentation of the supervisory process itself, especially if problems exist, is also necessary. This is true whether the supervision is being conducted privately or in a teaching institution.