A 2009 study conducted at four Harvard-affiliated teaching hospitals identified several breakdowns in communication between surgical residents and attending physicians (Ann Surg. 2009;250:861-865). Of 80 critical patient events identified in the study, 26 (33%) were not communicated to attending surgeons. Although residents felt that attending contact was unnecessary for safe patient care in 61 (76%) of these events, discussions with attending physicians changed management in 33% of cases in which they occurred. Further, the residents reported that, when contacted, all attending physicians were receptive to communication.
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.
Implementing 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.”