Residency Interns Don’t Always Know When To Ask For Help

A friend of mine shared with me how her teenage niece saved a small child’s life. Her niece, a counselor, was standing poolside waiting for instructional swim to begin for the young campers. The lifeguard turned his back for a moment, and one of the girls slipped into the pool, became disoriented, and began to flail. The counselor realized that the child was in trouble and jumped into the water, and rescued her.

The highly publicized “Libby Zion” case in the 1980’s where a young patient, in the care of an intern and resident, died, paved the way to the duty hour restrictions now in place for all residency programs across the country. The grueling schedule commonplace to residents in the past was deemed in part responsible for the care that the residents rendered that night. The fallout of this case also eventually led to the requirement that direct resident supervision be immediately available should the need arise. It is not a huge leap to conclude that resident fatigue coupled with lack of appropriate supervision of inexperienced physicians can lead to adverse patient outcomes.

Teaching programs all have attending physicians in house 24 hours a day, seven days a week to provide direct supervision if needed. One of the most important milestones that resident physicians can achieve is to recognize when they need help, as attending physicians typically are not following their residents around at night. However, for a new intern, even a phone call from a nurse asking for a “Tylenol order” can yield extreme angst about whether the medication is appropriate given all of the patient’s medical problems. Of course, making these kinds of decisions in independent fashion helps resident physicians begin to appreciate the responsibility they have and to begin to develop autonomy. After all, the ultimate goal for resident physicians is to be able to practice medicine unsupervised. Interns are counseled extensively during their orientation about how much support is available to them, and that they should and must call for help when they think they need it. However, because first year residents typically feel they need help for everything, they naturally begin to make triage decisions about what they think would be an acceptable reason to call.

Some events should always trigger a phone call to the supervising physician: a change in the patient’s status, a need for a procedure, transfer to a higher or lower level of care, or the death of the patient. However, some changes in the patient’s status are more subtle, and not so easily perceived, necessitating the need for several layers of supervision. In the early months of residency, there must be increased attending oversight, and perhaps debriefing sessions to go over all of the activity the intern engaged in to determine how they handled those tasks to evaluate their clinical acumen and critical thinking.

Medical educators cannot assume that their interns are always able to ask for help or know when to ask for help. We have to be at the sidelines demonstrating the right level of oversight until we know our trainees can swim.

 

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