In a later study, investigators at these same institutions reviewed interventions developed to reduce breakdowns in communication during inpatient surgical care (Ann Surg. 2011;253:849–854). The interventions included an information card designed for residents to carry detailing when a senior physician should be alerted, increased visits to surgical patients from attending physicians, and an effort to change the “culture” of the program, encouraging residents to reach out to senior staff. The chiefs also made it clear to their senior attending physicians that they were expected to take these calls and not to belittle a resident for making contact. After the intervention, the proportion of critical events not conveyed to an attending decreased from 33% to 2%, and gaps in the frequency of attending notification of patient status on weekends were almost entirely eliminated.
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April 2017Implementing Policies Encouraging Communication
Because departments seldom have the resources to implement these types of intervention programs on their own, they often need to obtain buy-in from the hospital or medical school administration. “Support for the time involved when you take an educator out of the clinical environment has to come from somewhere,” said Elisa Crouse, MD, MS, associate dean for graduate medical education at the University of Oklahoma College of Medicine in Oklahoma City. “Residents don’t pay tuition, so faculty salaries come from clinical revenue. We have this unfunded mission to educate, so you have to get buy-in across the institution to get the time and resources needed to do it well.”
Additionally, accreditation requires a policy for supervision. These policies have to address issues such as when direct supervision is needed at the bedside, when the residents can be indirectly supervised with a faculty member immediately available, and when indirect supervisions can be done remotely, said Dr. Crouse.
The policies should be structured to allow progressive autonomy as the trainee continues through residency. A first year resident in July is in need of closer supervision than a final year trainee in late June. “Throughout the program we always ask what their decision would be and the reasoning behind it,” said Dr. Cunningham. “We can require the attending to make the final decision but still guide [residents] in developing the reasoning and judgment behind their response.”
Faculty Support Is Critical
The outlook of those coming into the profession is another variable impacting communication between junior physicians and “veterans,” and the current generation of residents generally is better at speaking up than their predecessors. “Today’s residents … have been encouraged to ask questions of their teachers and mentors throughout their educational experience,” said Dr. Gray. “They value developing close relationships with senior physicians during residency training.”