How to Encourage Residents to Speak up

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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.

“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.