When should pediatric residents consult supervisors on issues that come up after hours?
In most teaching hospitals, after-hours patient responsibility is covered by resident physicians, who are always able to call a supervising senior physician for advice on handling situations that may come up. But which situations require immediate consultation and which can wait until the next day can sometimes be unclear. A new study from the MassGeneral Hospital for Children (MGHfC), published in the Journal of Pediatrics, finds significant discrepancies between pediatric residents and their supervising physicians regarding when supervisors should be called to help deal with specific after-hours situations. For some situations, even the supervisors disagreed among themselves regarding whether immediate consultation was required.
"Balancing the need for residents to develop autonomy with the level of supervision required to ensure safe and appropriate patient care is challenging," says Chadi El Saleeby, MD, MS, an MGHfC Hospital Medicine and Infectious Diseases physician and senior author of the report. "The variations we found between residents and attendings - and even more so among attendings - highlight the need for more structured, formal guidelines within programs and institutions." El Saleeby is an assistant professor of Pediatrics at Harvard Medical School.
While the Institute of Medicine has recommended that improved supervision of trainee physicians through more frequent contact with supervisors could reduce errors and improve the quality of patient care, the authors note that appropriate levels of supervision and how they are to be established have not been defined. Other studies have examined attitudes and practices regarding resident/attending communications in Surgery and Medicine, but this is the first to do so in Pediatrics. Prior to this study the communications guidelines for MGHfC residents were quite general. Guidelines were included in the residency manual and available online, but since they were not specifically incorporated into resident training, individual trainees could have been unaware of their existence.
The current study, which was conducted from December 2012 through January 2013, surveyed all MGHfC residents in Pediatrics and in the joint Medicine/Pediatrics program and their supervising physicians on the Pediatric Hospital Medicine service and in several other Pediatric specialties. The surveys presented 34 scenarios related to clinical situations, laboratory/radiology or medication issues, and logistical/social situations, which ranged from the need to consult another service in the hospital to a parent or patient wanting to be transferred to another hospital or leave against medical advice. For each situation, participants were asked whether the resident should consult the supervisor "immediately" - a term that was not defined - or if consultation could wait until the next day. Residents were also asked whether they were aware of the existing communications guidelines.
The surveys were completed by 62 residents and 50 supervisors, and statistically significant differences between group preferences were observed in half of the scenarios. Overall, most residents indicated they would call immediately in 18 scenarios, while more supervisors would choose to be immediately contacted in 26. In each scenario with significant discrepancies, more supervisors than residents would choose immediate communication. There was strong agreement on the need for consultation in the most serious scenarios - such as a patient death, rapid deterioration or a medical error requiring intervention - as well as on many situations when communication could wait - such as routine lab and radiology orders or drug reactions that did not require intervention.
Some of the most striking differences were in logistical/social situations - such as an angry parent or family member, the need to put a patient in restraints, aggressive patient behavior or the inability to carry out a procedure for any reason. In those and several other situations, residents preferred to wait until the next day, but supervisors preferred immediate consultation. The authors note that some of this discrepancy may result from residents' not appreciating how the advice or intervention of a supervisor could defuse a challenging situation. More than 60 percent of residents were not aware of the existing communications guidelines, and most of those who were aware of their existence indicated not knowing their specifics.
While there were no significant differences in the responses of residents based on how far along they were in their training, the researchers were surprised to discover some significant differences among supervising physicians, with senior attendings being more likely than junior attendings - who could be fellows or attendings in practice less than five years - to prefer immediate notification for situations including patient falls, new or worsening pain, an angry parent or family member, or the need for restraints.
"We had theorized prior to this study that differences in communication would exist among members of the health care team, but the magnitude of the differences was surprising to us, along with the disagreements among attendings, many in the same division," says lead author Deepak Palakshappa, MD, chief pediatric resident at the time of the study and now an instructor at the Children's Hospital of Philadelphia. "This study provides a first step toward improving supervision of pediatric medical trainees by defining these significant differences in communication preferences."
Based on the results of this study, the MHGfC developed new formal guidelines for resident/supervisor communications that were put in place for the current academic year. The guidelines were included in residents' welcome packets and orientation packets and in the introductory presentation the residents are given prior to each inpatient rotation. The guidelines are also available on the MGHfC website, and will be reviewed on a biennial basis. Future studies should evaluate how these guidelines improve resident supervision and ultimately patient outcomes, the authors note. MGHfC physician Lindsay Carter, MD, is also a co-author of the Journal of Pediatrics study.