Retrospective: When Supervision Wasn’t So Super

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A look back at the inflection point that brought 24/7 supervision of residents to emergency medicine… a move initially opposed by much of the EM establishment.

Today’s emergency physicians and residents might assume that 24/7 supervision of emergency medicine residents has been a standard requirement since the birth of EM residencies. That’s not the case. In fact, from the advent of the first EM residency in Cincinnati in 1970 until a landmark ruling by the Residency Review Commit- tee for Emergency Medicine (RRC-EM) in July 1989, many emergency medicine residents worked without attending EM supervision, especially at night. It might also be assumed that larger university academic medical centers would have been more likely to provide 24/7 attending supervision, but that was also not the case.

In an interesting flip of academic con- science, it turns out that 1970’s and 1980’s emergency medicine residencies that were at large non-university community teach- ing hospitals were more likely to have 24/7 supervision of EM residents. For example, at Henry Ford Hospital in Detroit, an EM group was providing around the clock staffing of the busy ED even before the EM residency was approved in 1976, and residents there always had attending supervision day and night. But at places like Johns Hopkins University, and other traditional university medical centers, there was usually no overnight EM attending supervision. The argument was that night time work would prevent academic emergency physicians from doing their important day time education and research activities. In truth, economics drove much of the decision-making. In large community teaching hospitals, the EM groups billed for services, had enough revenue to hire 24/7 coverage, and could pay a decent salary to attract teaching emergency physicians. The less well-resourced university programs were struggling to maintain and pay a decent wage to faculty members, and the added burden of night shifts was un- appealing.


As this debate played out in emergency medicine, the highly publicized case of Libby Zion, the 18-year-old daughter of a prominent New York family, who died at New York Hospital from drug toxicity after being cared for by unsupervised interns and residents, brought national attention to the issue. The “Bell Commission” in New York City developed recommendations, that later became statewide, on mandatory 24-hour attending physician supervision of residents. Lewis Goldfrank, MD, who was building the NYU/Bellevue emergency medicine program, was on the Bell Commission, and used the new regulations (active in 1989) to increase his emergency medicine attending staffing, and eventually to get the Bellevue EM residency approved.

When the RRC-EM proposed mandatory 24-hour attending supervision of residents in 1985, there was an immediate outcry. Brooks Bock, MD, who was on the RRC-EM remembers: “People were very angry . . . saying… you’ll close down our program.” Both the ACEP Academic Affairs Committee and the Society for Teachers of Emergency Medicine formally opposed the new requirements. The University Association of Emergency Medicine (precursor to SAEM) was silent on the matter. Heated editorials appeared in EM journals and newspapers. Peter Rosen and Vincent Markovchick at Denver General Hospital wrote: “Emergency medicine has an unparalleled opportunity to provide a new kind of education and patient service… Let us not sacrifice our opportunity for leadership for convenience of lifestyle.”

After more than 3 years of wrangling, the debate eventually swung in favor of mandatory 24/7 attending supervision of residents. The ACEP Board of Directors, in an unusual move, overruled its Academic Affairs committee to support 24 hour supervision, but many in the EM academic organizations and institutions continued to oppose the requirements. Finally, in 1989, with ACGME pressure, the RRC- EM changed their special requirements to mandate 24/7 attending supervision of EM residents.


Doing the right thing, after contentious debate, helped to build the academic credibility of emergency medicine at a time when it was just becoming a primary board in the American Board of Medical Specialties. Developing programs used the new mandate to push their institutions for funding for more EM faculty – Gabor Kelen, MD, the director at Johns Hopkins University was able to use this mandate to move toward full departmental status in the medical school.

What is the lesson for today, as we now accept that full-time supervision of residents is fundamental and ethically and morally imperative for our emergency patients? Maybe it’s that things that we now do that are part of pattern or tradition, but create some tension with our sense of “what’s right” should be examined, debated, and potentially changed for the betterment of education and patient service.

* This essay was excerpted from chapter 7 of Dr. Zink’s book Anyone, Anything, Anytime.



Brian J. Zink, MD is a Professor and Chair in the Department of Emergency Medicine at Alpert Medical School of Brown University. Dr. Zink is also the author of Anyone, Anything, Anytime- a History of Emergency Medicine (Mosby Elsevier, 2006)

1 Comment

  1. Mark Edwards on

    Hi Brian:

    Hope you are well. I am working in a teaching hospital in central Queensland, Australia and there are very few programs (at least in Queensland) that have attending staff for direct supervision for overnight shifts. We are on-call and come in at the drop of a hat – or drop of “a bundle” as they say here when someone goes unstable. No one wants to work over night and the hospital system doesn’t seem to want to pay for the increased staffing required.

    Nice article. I’ll send it to my colleagues.

    Kind regards,

    Mark Edwards
    Emergency Physician
    (UofM Residency grad, 2005)

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