Guiding an individual through the years-long transition from new MD to fully qualified practitioner takes supervision and an environment that encourages communication at all levels. One major reason is that residency programs need to balance trainee learning and independence with patient safety.
Explore This IssueApril 2017
“The key is the balancing act between allowing a trainee to grow confident in their abilities while still preventing unnecessary mistakes,” said Michael Cunningham, MD, otolaryngologist-in-chief and Gerald B. Healy Chair in pediatric otolaryngology at Boston Children’s Hospital.
One impediment to this communication traditionally has been the hierarchical nature of medicine. How does a physician-in-training approach someone who may be one of the world’s top experts in their field?
Escalation of Care
While the Accreditation Council for Graduate Medical Education (ACGME), via the Otolaryngology Residency Review Committee, provides specifics as to what is expected from residency training programs in the area of attending/resident clinical communication (see Harvard Otorhinolaryngology System Triggers for Attending Communication, p. 28), establishing these lines of communication starts with orientation to the program itself. The faculty and staff should be very clear that residents are encouraged to ask questions and seek advice from more experienced staff.
“Residents absolutely need to know that they should call us if they feel uncomfortable with any issue,” said Stacey Gray, MD, director at the Harvard Otolaryngology Residency Program and assistant professor of otolaryngology at Harvard Medical School in Boston. “The residents know that patient care is the paramount concern in all situations. They are expected to do the right thing for the patient. If they are concerned about making a clinical decision, the consequence of not calling an attending for assistance and making the wrong decision for patient care should override any apprehension about making the call.”
In the clinical setting, certain events should always be brought to the attention of a senior physician. Residency programs often have lists of things that should trigger an “escalation-of-care” call. Although the criteria differ from program to program, they usually cover major changes in condition such as hospital admission, transfer to a higher level of care, changes in medicines, or emergency care of any kind (“Clinical Scenarios In Pediatrics Otorhinolaryngology That Require Prompt Attending Notification”).
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.”
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.”
Department chiefs and program directors are essential to developing an environment in which trainees feel comfortable speaking up. It rests on the shoulders of senior staff to do away with any lingering belief in the traditional adage a senior surgeon might share with a junior resident, “Call me anytime, but remember, it is a sign of weakness.”
In a recent editorial, Douglass Smink, MD, MPH, and John T. Mullen, MD, both with the department of surgery at Brigham and Women’s Hospital in Boston, recommended that all surgical educators incorporate escalation-of-care training into the curriculum for junior trainees, not only because they say it is quality education, but also because the training has a high likelihood of improving patient care and safety (Ann Surg. 2016;263:427). Drs. Smink and Mullen said that escalation of care, like many other non-technical skills, is an essential skill that can be taught and improved, and should be included in the curriculum for all junior physicians. They urged senior physicians to provide support to residents so that speaking up in the name of patient safety is both encouraged and expected.
Kurt Ullman is a freelance medical writer based in Indiana.