Research suggests that it costs more to provide care at academic medical centers in the United States. This is due, in part, to a higher frequency of testing and other resource use that commonly occurs in teaching settings. Cost-effective care is among the milestones that are now used to evaluate emergency medicine (EM) residents and accredit EM residency programs, says Stephen R. Pitts, MD, MPH. Some evidence suggests that resident supervision may improve patient outcomes, but few studies of supervised learning have explicitly evaluated resource use as an outcome.

Comparing Supervised vs Attending-Only Visits

For a study published in JAMA, Dr. Pitts and colleagues compared resources used in supervised visits with attending-only visits using a nationally representative sample of patient visits to EDs. The investigators defined three ED teaching types by the proportion of sampled visits that were supervised visits: 1) non-teaching EDs, 2) minor teaching EDs (half or fewer supervised visits), and 3) major teaching EDs (more than half supervised visits). Hospital admissions, advanced imaging, performance of any blood test, and ED length of stay were assessed as dimensions of resource use.

When compared with attending-only visits, supervised visits were linked to more frequent hospital admissions and advanced imaging as well as a longer median ED stay, but not with blood testing. A secondary goal of the study was to compare supervised visits between minor and major teaching EDs. For this part of the analysis, supervised visits in major teaching EDs—when compared with attending-only visits—were not associated with hospital admissions, advanced imaging, or any blood test, but were linked to longer ED stays.

“Our analysis confirms that there is consistently higher use of several ED resources among supervised visits, even after adjusting for other possible determinants,” Dr. Pitts says. “Care is more expensive in academic medical centers, and justifies the Indirect Medical Education subsidy provided by Medicare. We found that increased ED resource use was due mainly to residents seeing patients in minor teaching EDs. In major teaching EDs, there was no increase in resource use except for a longer stay, which in turn might be due not to teaching encounters but to resource constraints of public hospital EDs.”

Important Implications on Training EM Residents

According to Dr. Pitts, the study indicates that teachers and residents need to consider that cost is an element of high-value healthcare. “When EM residents are exposed to high-cost teaching styles, they may take these styles with them as the move on to community practice,” he says. “We need to demonstrate wiser resource use in both teaching encounters and in the teaching curriculum. Though instruction in quality is important, understanding the cost of care is fundamental to a sustainable healthcare system.”


Pitts SR, Morgan SR, Schrager JD, Berger TJ. Emergency department resource use by supervised residents vs attending physicians alone. JAMA. 2014;312:2394-2400. Available at:

Farnan JM, Petty LA, Georgitis E, et al. A systematic review: the effect of clinical supervision on patient and residency education outcomes. Acad Med. 2012;87:428-442.

Marcotte L, Moriates C,Milstein A. Professional organizations’ role in supporting physicians to improve value in health care. JAMA. 2014;312:231-232.

Pitts SR, Vaughns FL, Gautreau MA, Cogdell MW, Meisel Z. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21:497-503.