The Next Generation is a BWH Clinical & Research News column penned by residents, fellows and post-docs. This month’s column is written by Joshua Jolissaint, MD, a first-year resident in the BWH General Surgery Residency program, who discusses the balancing act of graduated autonomy, patient safety and escalation of care that interns face.
Each summer, several thousand medical students walk across a stage in front of their family and friends, receive a diploma from their respective institution and become physicians. With this transformation, they also assume newfound responsibility for the lives of others and are often the primary responding physician for sick and critically ill patients.
This transition from observing the practice of medicine while in medical school to serving as the first line of care is rapid, anxiety provoking and potentially dangerous. Regardless, interns serve an essential role in hospital workflow, tackling the mundane tasks of writing daily notes, placing orders and changing dressings, while also responding to acute changes in hemodynamic stability and being the point of contact for any variety of consulting physicians and ancillary hospital services.
As a surgical intern, I take pride in continuing the history of graduated responsibility in surgical training, fulfilling my duty to my patients, being a compassionate advocate on their behalves and having the ability to treat their diseases. Yet, as a new physician, I also experience routine discomfort with tasks such as prescription dosing, invasive procedures or testing, and explaining (or even understanding) radiological or pathological findings to patients and their families. Fortunately, the Department of Surgery at Brigham and Women’s Hospital embraces a culture in which senior residents make themselves perpetually available, attending surgeons are easily approachable and interns know they can always ask for help, no matter how trivial the question may seem. During our orientation, both program leadership and senior residents alike instruct us that any resident concern is warranted, justified and will be taken seriously. Moreover, we will only be faulted if we fail to ask for help when should have.
Early during my night rotation on the surgical oncology service, one of my chief residents epitomized this philosophy when he told me, “I want you to call me any time you feel uncomfortable.” Obviously, this is a generous offer with non-specific and nebulous inclusion criteria. I’m confident that by making that statement, he had already accepted that his phone might ring several times each night. However, I believe we were both comforted in knowing that no measure of hierarchy or fear of looking ignorant would prohibit me from providing the best care for my patients. And, as is the natural course of residency, the repertoire of situations and disease processes I’m “comfortable” approaching, solving and treating expands each day.
I was recently interviewed by Laura Landro from The Wall Street Journal about this very topic—more specifically, about the card developed by Dr. Atul Gawande detailing situations in which trainees must contact the attending physician. Early during my first month of residency, my chief resident was briefly unavailable and she informed me that if anything should happen with my patients, I should page the attending physician directly. Just prior to discharging a patient, a radiologist informed me that she saw possible free air in the patient’s abdomen—a surgical emergency. I immediately paged the surgical attending and had a collegial discussion about the patient’s clinical situation. Fortunately, after collating all the available data, we concluded that the radiologic finding was likely incidental or artifactual. This scenario was nothing extraordinary or heroic and, fortunately, did not affect the patient’s health. The more important takeaway was that I felt comfortable calling my attending, both allowing for rapid action and ensuring the attending knew the circumstances around the patient’s care.
Although identifying a few specific situations is important, there will always be scenarios in which an intern or resident should, regardless of comfort level, discuss care with a more senior physician. In the past, calling a senior resident or attending may have been viewed as a sign of weakness; however, this project sought to change that mentality into one in which calling was a metric of safety and appropriate decision-making. Establishing a framework in which certain events, changes or situations must be escalated allows for more transparency in patient care, better communication within the primary team, and faster and more appropriate treatment.
In an era of continual quality improvement within the health care system, there are innumerable interventions that are intended to—but, ultimately, may not always—improve patient care. Often, these interventions are cumbersome, difficult to navigate and burdensome to actually providing care. However, by removing the artificial barrier between attending surgeon and house officer at the Brigham, we’ve implemented a change that tangibly improves both the quality and safety of patient care and the training environment of the general surgery residency. Ultimately, it establishes a model in which anyone, no matter their level of education, training or experience, can voice their concerns for the safety of our patients, and I personally feel privileged to train in this environment.