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MEdIC Series | Case of the Unseasoned Senior (SMACC Edition)

2017-01-04T18:32:44+00:00

SMACCWe had the remarkable pleasure of facilitating a MEdIC workshop at the Social Media and Critical Care (SMACC) conference in Chicago this past month. We shared our process with those who participated and spent time developing cases. We’d like to thank the participants from our workshop for their hard work!  The below is one of the final products that our amazingly engaged and enthusiastic group come up with. The case generated meaningful discussion in our SMACC live session, and we hope that it will be as engaging in the online forum! We look forward to hearing what you think about our Case of the Unseasoned Senior.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the Unseasoned Senior (SMACC Edition)

by Rebecca Wood & Sarah Luckett-Gatopoulos

Mrs. Smith was a 50-year-old mother of three and had been admitted to hospital under the surgical service for the past 3 days. Debbie, a first-year resident, had been rounding on her every morning and was growing increasingly concerned with her clinical status..She had originally presented to hospital with diffuse abdominal pain, fever, and a high white count. The team had initially scheduled her to go to the operating theatre for a possible complicated diverticulitis. Since her admission, however, her management plan had been changed several times by the new Chief Surgical Resident, Sam Waltz.

This morning, Debbie had noticed that Mrs. Smith was somnolent, pale and running a high fever despite 3 days of intravenous antibiotics. Debbie knew she was growing increasingly ill, and was concerned that she might crash at any moment.

Sam seemed unsure of himself and had not created a definitive treatment plan for Mrs Smith. The usual half-hour morning rounds were now taking the team over two hours. Decisions were made and changed on a daily basis and the past few weeks seemed to become a ritual of constant interruptions, poor planning, and indecision. Debbie had voiced her concerns regarding Mrs. Smith to Sam but he had opted to watch and wait for one more day

As Debbie sat at the nursing station writing a progress report in Mrs. Smith’s chart, she was approached by Dave, a highly-reliable floor nurse.

“Debbie,” he began in a stern tone, “Mrs. Smith’s family would like to speak with you. They are really upset that nobody has explained what is going. Frankly, I’m not sure what the plan is either.’

At that moment, Dr. Singh, Debbie’s surgical attending, strode onto the ward.

“Dr. Singh!” Dave called, “Debbie and I were just discussing the plan for Mrs. Smith. She’s not responding to the antibiotics. Someone needs to make a decision.”

Dr. Singh looked at Debbie, surprised.

“Mrs. Smith has been under our care for three days,” he said. “No one told me she wasn’t improving. Why don’t we have a plan for her yet?”

Debbie hesitated. She knew that the new Chief Surgical Resident was sinking, not swimming, and she knew patient care was suffering as a result. But should she really throw him under the bus?

Key Questions

The SMACC MEdIC workshop participants would like to pose these questions to the readership:

  1. What is Debbie’s responsibility as a junior, off-service resident in this situation? Is there a way to ensure good patient care without sacrificing the relationship with her senior?
  2. Imagine you are Dr. Singh. How would you deal with the faltering Chief Resident?
  3. What is Dave’s role in dealing with the struggling senior? As a nurse, is there a role he can play in the Chief Resident’s education and ensuring adequate patient care? Who should he speak to and how?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Brent Thoma, MD, FRCPC from the University of Saskatchewan
  • Jacky Parker, MB, BS, MHSc, CCFP(EM) from the University of Ottawa

On August 7, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of the Unseasoned Senior. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary. That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at BoringEM.org
Founder of manuetcorde.org
  • Lillian Kao

    I would take care of the patient first and foremost. Then, I would meet with the resident privately to determine what issues contributed to his indecisiveness and to see how I could help him. I would use feedback from everyone on the patient care team.

    It is also important to remember that the senior resident’s decision-making and leadership skills are a reflection in part of the training he received. Thus, if a senior resident has significant deficiencies then we as faculty are partly at fault as well — for not addressing them earlier or for allowing a resident to take on a role for which he is not ready.

    @lilliankao1

    • Thanks for breaking the ice, Dr. Kao! We are excited to get all multi-disciplinary here for our cases, so we love having a surgeon like you comment!

    • Tamara McColl

      I really like your comments on taking ownership over resident performance and leadership. I completely agree and, as an R5, feel the same way about my junior residents.

      This is a loaded question, but how do you think the culture of “I need to deal with this myself and won’t bother the staff unless it’s an emergency” can be changed so that residents feel less compelled to make uncertain decisions and may approach their staff earlier in the patient care process? We see this all the time from various consulting services in the ED and sometimes have to escalate things ourselves when we see fairly green residents trying to sort out very sick/complex patients on their own.

      • Absolutely. I get a decent number of calls from my EM attending colleagues (without my residents’ knowledge) to ensure I’ve been adequately informed (and I frequently haven’t). I think that’s a start—if different services don’t have a good relationship where such calls can be made, patients will suffer.

        As for improving resident communication with attendings, that’s only possible after a great deal of “safe space” example setting—and can be undone with one irate comment. Residents will run patients on completely different services by me because I’m “safe” (or maybe a pushover); that’s despite the fact that almost all of my colleagues would rather know about the patient than have the resident “not disturb” them.

        • I like that the EM attendings call you too. 😀 I often do that when I think something might be politically charged – or I’ll pop by to have a chat when I see them come down. 😀

      • Tamara, the key lies in consistently being approachable. I’m very clear with residents who haven’t worked with me before that you will never, ever get in trouble for calling me, even if it may not have been necessary, but you WILL get in trouble if you should have called me and you didn’t. And even in the middle of the night I try to be very patient in listening to what they are telling me (not always easy, but critical to developing trust!).

        • S Luckett G

          Dr Cochran, it’s interesting to hear you say that – I wish more attendings were more explicit about preferring to be called vs. not called. Last year, as an off-service junior, I think I spent more time stressing about whether I should be calling my attending overnight than I did on patient care! it can be a hard line to toe when you want to be seen as a smart and independent resident who can make decisions and accomplish good patient care without excessive direction, but you also want to ensure that patient care is safe and effective.

          • SLG, I consistently had the same fears as a resident. However, I was only ever chastised for not calling; despite my expectations, I never once heard “can’t you handle that” or anything similar. Now that I’m an attending, I see the other side, too. I’ve never heard a colleague complain that he or she was called.

            My best tip: call, explain the problem, and say “I’d like to do this:” with your plan. Some of my residents will even send me text pages with their plans “unless you’d like me to do something else”. I’m fine with that, and imagine many others are too.

          • S Luckett G

            Thanks for validating my fears! I agree that I have rarely had an attending chastise me for calling (though there has been exasperation in the voice of my chief once or twice when I made that 3 a.m. call for help).

  • Amalia Cochran

    Kudos to Dave, RN, for speaking up on behalf of the patient when he has concerns about their care. I’m a big believer that bedside nurses are often our eyes and ears, both in terms of patient care and trainee behavior.
    I agree wholeheartedly with Lillian that the senior resident’s behavior is likely not occurring in isolation and it’s crucial to remediate. His decision making doesn’t sound safe to me. And while no junior resident wants to be a “tattletale” it will be important for Rebecca to provide an objective report of the course of events here. Only with that information can proper remediation occur.

    • Thanks for your comment Amalia – do you think that as an attending you can encourage Rebecca (the junior) to provide you useful feedback somehow?

      • I would simply ask her (privately and confidentially) to walk me through the patient’s course of care and to describe when she had concerns and how they were/ were not addressed. The key is to try to keep it very objective and not personalize it as being about Sam as an individual.

  • Love it, and agree completely with the wonderful @lilliankao1.

    I’ll limit (well, for now 🙂 ) my comments to what the attending should do.

    Step 1: Do whatever the patient needs. The patient’s nurse is already doing this. Dave can continue to take care of this patient—and future patients—by directly speaking with the attending surgeon as well. As attendings, we must take nurses’ comments about residents quite seriously—even those of us dedicated to teaching don’t interact as often with trainees in direct patient care as much as the nurses do.

    Step 2: As an attending, reassure the intern. She’s new, she’s trying her best to both respect traditional “hierarchical” roles while also caring for her patient. We’d all love for her to feel more comfortable directly discussing her concerns with the senior resident or the attending, but custom has beaten that in to too many as “going over the head” and worthy of punishment. Correcting this notion requires reassurance and appropriate care of the attending and the entire residency program. Make sure she understands that she won’t be punished—or, perhaps worse, thought a “snitch”—if she comes to me with concerns.

    Step 3: Figure out what I’m doing wrong. Why didn’t I pick up on the patient’s worsening condition myself? Am I not rounding adequately? Am I not providing enough supervision? Have I not talked with the patient’s family regularly? Am I putting a resident into an inappropriate situation?

    Step 4: Provide better direct supervision of the senior. Ask him to run the list frequently. Round with him. See my patients myself. Do my job.

    Step 5: Figure out what’s needed for the success of the senior. As Lillian put it, meet with him. Ask him how he felt about what’s going on. Talk to the other people involved with this situation and with other people who’ve worked with him previously. Yes, he’s our responsibility—not just a target for finger-pointing.

    • I’m seeing a trend here with prioritizing patients first!

      This is a paper that speaks to supervisory skills of Internal Medicine attendings.
      “Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist.”

      Wondering if it applies / speaks to the way surgeons see the world too??

      http://www.ncbi.nlm.nih.gov/pubmed/25901877

      • Similar studies have been done for surgeons, but as stereotypes might suggest, they tend to have a different distribution than some other fields. Many (anecdotally) seem to fit into one of the “all” or “nothing” categories. Improving attending teaching is both a personal and professional challenge.

  • Andrew Wright

    I agree with Dr. Kao. In the scenario as described there is culpability in the part of the attending. In the modern era it is not acceptable for the attending not to have rounded or know about his/her patients. One unintended consequence of this increased oversight, however, is decreased autonomy for senior residents, which can sometimes be reflected as indecision.

    • Absolutely—and it’s a tough balance. Personally, as a junior attending, I have frequently gone over too much to one side or the other. Any tips on maintaining that balance? Really not a fan of “secretly” monitoring patient care, but maybe that’s the answer.

      • How do we become the hidden safety net?? Thoughts?

        • Andrew Wright

          Not to be hidden – need to be involved. It’s a difficult balance between running the show and letting the residents have autonomy, and I can’t claim to be perfect. I try to make sure the residents feel ownership and force them to make (and present) their plans. I don’t accept “Well, we could get some labs/imaging/etc.” When I get that plan I respond with “You’re the doctor, what are you going up do?” If I disagree I’ll explain why.

          • I am notorious with our residents for asking them- even at 2 am-
            “What do you want to do?” and demanding a specific answer. That’s how we foster clinical reasoning skills and can best identify residents who are struggling with them.

          • Sounds good, but I always face the idea of too much vs too little… And also I am often now finding myself relaxing a bit in terms of my own practice within what would be “acceptable” – taking in multiple acceptable possible answers… BUT this is not easy for me as a junior attending. Often I do want my way… 😉 Any tips?

          • I truly think it gets easier as you get more experience. I know that I was less flexible earlier in my career and would negotiate them to what I wanted to do. Now if I realize that it won’t result in any harm I’m willing to let them try something that isn’t too crazy (still appropriate care) but woudln’t be what I can do. The mantra is “As long as I can get you out of trouble, I’ll let you try. If I can’t, it’s my situation to handle.”

        • Tina Choudhri

          As an attending on any service in the academic environment,it is our job to oversee our senior residents in the background. We need to have our eyes and ears on every patient and plan – but not interfere too much with decision making if the patient continues to fare well and the plans are reasonable. When the plans are wrong and/or the patient is deteriorating, we should have already been aware and speak up. It is not acceptable for days to go by and not be aware of a patient status. That’s not the resident’s fault – that’s the attending’s responsibility to be in the know of his/her patients.

  • GirlfriendMD

    There have been some great comments already regarding putting the patient’s needs first. Dr. Singh definitely has the responsibility to step in and make a plan for the patient, since the senior resident is not.
    Also, as previously mentioned, where has Dr. Singh been for the last 3 days? Why has Dr. Singh not known this patient’s course until now? Dave has definitely done the right thing by stepping up and stepping in, but the attending’s role is to attend the patients along with the residents.
    I had a great attending as a family medicine resident who would essentially groom the senior residents for running rounds and delegating tasks to junior residents on the team. At the start of the inhouse rotation, he would run the rounds on day one and then turn it over to the senior on the team. He would interject only when he saw our team missing treatment options or keys to the patient’s status and progress. He would then meet with the senior at the end of rounds to discuss what went well, what was working and what wasn’t. If he saw needs in the team, he’d address them privately and individually, often praising publicly during rounds when things went well. The key, I believe, was that he was there are every patient visit with us, he didn’t “hear” about patients days later. He was familiar with every patient and their plan. In our program, the attendings rotated in-house coverage (we were a community program), so each attending would spend a week on the in-house rotation. So all of the attendings were different: some would lead rounds, but the best learning week was always the weeks were always the weeks that he would push us to lead our own rounds, to be a team with him in the background to help guide us, more like a GPS system than a cab driver.

    • Tamara McColl

      Thanks for sharing your thoughts! Sounds like he had a great balance of overseeing excellent patient care and providing his residents with autonomy to improve critical decision making and build leadership skills.

  • Sherri Ludlow RN

    As a seasoned (senior) nurse, I assure you that my priority is the safety of my patients. Having worked in both teaching and non teaching hospitals, I understand and value the learning process. Dave did what is expected of all nurses. When we have a concern re our patient, we go up the chain of command until our concerns are addressed. We don’t do it to undermine the learner, but to ensure positive patient outcomes. I’m slightly concerned why it took the nursing staff 3 days to report to the attending that the patient wasn’t responding to treatment. Health care is a team based system and requires constant communication between all members.

    • Hi Sherri! Love that patient-care is your top priority… I’m just not sure we always communicate this well to the learners that are part of this “chain of command”? Any thoughts on how to smooth it over with the resident-in-question afterwards?

      • Sherri Ludlow

        I’m not sure if smoothing it over afterwards is how we should be thinking. Knowing before residency that hospital staff, in particular nursing staff, are a valuable resource, is important. Understanding that we are a safety net, for them and their patients will help their learning. Perhaps as a point during orientation, residents could be made aware of this “chain of command” and that it isn’t punitive if a nurse goes from the jr to the sr and perhaps the attending.

        • S Luckett G

          Wholeheartedly agree. I think that sometimes it is easy to forget as residents that nurses catch our falls all the time. I try to remember that when a nurse asks me to clarify an order or explain something, or when he or she speaks to my attending instead of me, it is because there is a concern about possible poor outcomes for a patient. I try to step back and look at where I may have gone wrong when this happens…sometimes I see that I am happy with my course of action, and other times I reconsider. Nurses are one of our most valuable resources, and my respect for them is immense.

  • Andy Little

    So, patient care always trumps seniority, personal pride or the pecking orders of medicine. But, unfortunately I’ve been here. As an intern I received a ED sign out from a senior (PGY-4) of a patient who was “just here to get pain meds”. I was told she was getting a CT scan of their abdomen for documentarians sake but “they were just faking” to scam some IV pain medicine and they would most likely be admitted to medicine for observation so they could “score 24 hours of IV pain medicine”. Luckily for me I had admitted them to hospital a few months before so after my senior left I went to evaluate they. This was not the same patient I had seen months prior, thet were sick as #%$&!! I remember ordering a few extra labs. The result was a lactate of 18, WBC of 27, a CT showing hemoperitoneum and the patient getting their entire small removed as it had twisted on itself. This was my first lesson in two things; just because someone has been a doctor longer than you doesn’t make them any better in a particular moment, and that you sign your sick patients out at the bedside…

    • Lillian Kao

      Andy’s story illustrates how patient care is a team effort. An unmentioned factor here is that the leadership at an institution can also play an important role in creating a culture whereby everyone is empowered to speak up to promote safe patient care.

    • S Luckett G

      I think that many of us have been in a similar, scary situation! It is easy for each of us to make mistakes, and maybe a willingness to see and admit that can open us up to feedback that violates the hierarchy. What use is the hierarchy anyway, if it doesn’t facilitate good patient care?

      Andy, what did you say to your senior?

  • Anna Patricolo

    This is a really interesting , and reading it, I have a few thoughts.

    As a resident, I think what Amelia Cochran has said about allowing sensible management plans that are not exactly what the consultant would do is really important. I have worked in Emergency Departments in both the UK and Australia, where provisions for supervision are very different. In the UK you are expected to manage your patients reasonably independently but you are always encouraged to ask for help from your senior when you need it. This encouraged ownership of patients, safety netting, and development of an acute awareness of your limits. In Australia, we are expected to discuss every patient with a senior. This is helpful if done well, as it protects the patient and has a lot of potential for direct education. However, there are many situations where as a resident, my plan has been changed on various details, such as analgesic choice (for example) without much discussion of the reasons, with the result that my confidence in my own management skills has not developed to the same extent as they did in the UK. This is compounded by different seniors having different preferences for analgesia which does not help me to develop my own schema to manage pain. I think the most important factor in a good supervisor is knowing that they are available and approachable for help when you need it, and I think it is helpful if this is explicitly articulated at the beginning of the post. Supporting the implementation of sensible managment plans, even if they are not exactly what the senior would do, helps to develop confidence in junior staff, and focusing supervision on justification of the plan, and coming up with contingency plans in case plan A doesn’t work is more educationally valuable than just being told what to do, and improves patient safety over the longer term.

    Having been in a similar situation as Debbie during my first post as an intern, I think it is also important to make clear to junior staff that the patient care takes priority over the hierachy, with clear instructions about where to go when the hierarchy fails. I was in a situation (on a surgical ward) where my patient had been undermanaged by both my locum registrar and was deterioriating, and I was unable to contact the locum consultant responsible for the patient. After a lot of trouble, I discussed the case with one of the other surgical consultants on the team who was surprised that I hadn’t contacted him for assistance, but it hadn’t been made clear to me in advance who to go to next when I had problems getting help from the hierarchy. It would have helped if my views about my senior had been sought out earlier as there had been a number of less serious situations where I had been having difficulty getting adequate help from this registrar which could have highlighted that there was a problem earlier. Junior staff can provide a unique perspective on middle grade staff, but often, especially as an intern, it is not clear who to approach with concerns and indeed when to raise concerns. Explicitly seeking feedback from junior staff may help.

    Sorry for the long ramble…Thanks for the great case and opportunity to discuss.

    • S Luckett G

      Anna, as a resident in Canada I have run into a lot of variability in how patients are managed, and your words ring true. On some services, and with some seniors and attendings, I have been expected to manage my patients as you’ve described in the UK system. With others, I have been expected to function more as you describe the Australian system. I have noticed that my biggest leaps in growth clinically have occurred when I have been operating within the UK-style, but that I have felt more confidence in patient safety and received greater direct education within the Australia-style. I think I agree that any reasonable plan by a resident that does not put the patient in harm’s way should be supported; I believe it helps us develop the confidence and autonomy you describe.

  • Imagine it this way. “The co-pilot knew the plane didn’t have enough fuel to fly around the storm and would probably crash into the ocean. Should s/he really throw the Captain under the bus?” The problem here is the dysfunctional culture of medicine, where being armed with improved situational awareness is an affront to someone’s ego and the patient comes in second. At our receiving hospital anyone can activate the rapid response team, including the patient’s family.

    • Tamara McColl

      That’s such an interesting way of looking at it, Tom! Thanks for sharing your thoughts!

  • @signindoc

    There are a number of important issues in this very good simulated case.
    While it seems to centre on inadequate decision making on the part of one individual, it actually highlights a problem in the hierarchical structure of medical care delivery.

    I have outlined some thoughts from Dr Singh’s perspective, but there many issues to capture from different angles.

    [As an Attending Staff, I have put down some ramblings about Dr Singh. I appreciate that this starts from before the case. I am less qualified, but prepared to tackle it from the point of view of other members of the Team and from Mrs Smith’s family. I am also prepared to tackle the question of Sam’s performance if you want]

    Dr Singh is the most responsible physician (MRP) for Mrs Smith’s (and presumably other patients’) care. The situation could have potenitally been avoided by one of several commonly used practices that I have seen carried out by Surgeons and Physicians alike.

    (i) Dr Singh sets the expectation for communication on the Team. The Attending Staff should know the Charge Nurse on the unit, and it should be clear that there is no barrier to direct contact between the Charge Nurse and the MRP when The Charge Nurse deems that this is necessary. Similarly all Team members should have direct access to Dr Singh. Dr Singh should make it clear to all new medical staff that this is the way the Team
    works, and that it is no reflection on anyone’s ability if Dr Singh is called about an issue.

    (ii) Dr Singh should be visible on the ward. This is harder for surgeons who have OR responsibilities, but a simple check in at the nursing desk “everything OK?” and communication outside of formal rounds with individual team members “Debbie, how are your patients doing?” often helps.

    (iii) Dr Singh needs to assess the strengths and weaknesses of his Team at an early stage (and number ii helps with this). There is no substitute for one on one conversations about strategies for patient care. These should be case based:
    “Sam, Mrs Smith came in with what appeared to be complicated diverticulitis, what are your indications for surgical intervention in this circumstance?”

    “Sam, what would be your criteria for antibiotic failure in Mrs Smith’s case?”

    (iv) Dr Singh needs to have a method of hearing about all the patients under his care at a minimum of twice a day from the housestaff taking care of them. The basics are “any problems overnight with anyone?” in the morning, and “anything to hand over to the on-call team?” at the end of the day. The other requirement in this line is “is there anyone anybody is worried about and that you want me to see?”

    (v) Dr Singh should have seen Mrs Smith (and all of the patients) more than once in three days.

    I hope these ramblings help.

    • Tamara McColl

      You brought up a lot of excellent points! I completely agree that excellent patient care stems from exceptional leadership from the senior-most physician – the MRP. How can we work towards ensuring the uniformity of this structured team approach? It seems so attending-specific.. i.e. some will take the time to make themselves available and follow the team-based schematic you outlined above, but others will practice a more “old-school” approach and put the brunt of the responsibility on the senior resident (sink vs swim).

      • S Luckett G

        I would add that one of the trickiest parts is that even the most team-based attendings are sometimes so busy with multiple responsibilities that the idea of bringing them a concern (that a junior might assume is an overreaction, since the senior doesn’t seem to be reacting) can seem like the wrong decision.

        • I can definitely see that concern. I’m not sure it helps, but I’m certain the attending would want to know—and though it’s possible they’ll be frustrated (and may not demonstrate it well to you), it really will be the senior making more work for them, while you’re clearly most interested in taking care of the patient. It can be hard to rely on that sometimes, but it’s the right thing to do.

          One of my seniors once told me, “if you really don’t want to do something, it’s probably the right thing to do.”

          • S Luckett G

            Isn’t that just always the test of the thing you have to do! I have often caught myself saying, ‘Uuuuuuuugh, I really don’t want to. Okay, I know I have to’ and then doing the dreaded thing!

  • bo

    sorry late to join the discussion just sign as a member of ALiEM,

    • S Luckett G

      Hi Bo, and welcome to ALiEM! Thanks for joining us, and for your excellent recommendations.

      As one of the authors of the above case, your point regarding the title is well-taken.

      • bo

        hi please check my comment on the posting last week many thanks Dr luckett
        best
        Tom