title: Perceptions of emergency medicine residents and fellows regarding competence, adverse events and reporting to supervisors: a national survey.
abstract: OBJECTIVE
  We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors.
  
  
  METHODS
  A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec.
  
  
  RESULTS
  Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 re-spondents (30.5% [95% confidence interval (CI) 19.9%-41.1%]) agreed with the statement, "I sometimes feel unsafe or un-qualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician" and 32 of 81 (39.5% [95% CI 28.2%-50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%-52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%-59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%-51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%-49.3%]), admission decisions (13/79, 16.5% [7.6%-25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%-25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%-61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%-50.2%]).
  
  
  CONCLUSIONS
  Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.
authors.affiliation: University of Toronto, Ontario, Canada. steven.friedman@uhn.on.ca
authors.forename: Steven Marc
authors.initials: SM
authors.lastname: Friedman
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Sowerby
authors.forename: Ray
authors.initials: R
authors.lastname: Guo
authors.forename: Glen
authors.initials: G
authors.lastname: Bandiera
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D002170:Canada; D002983:Clinical Competence; D004635:Emergency Medicine / Q000193:education*; D005257:Fellowships and Scholarships; D005260:Female; D006801:Humans; D020407:Internet; D007396:Internship and Residency; D008297:Male; D008611:Mentors; D015279:Organizational Culture; D010820:Physicians / Q000523:psychology*; D011795:Surveys and Questionnaires