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MEdIC Series: The Case of the Solo Senior

2017-05-11T15:05:12+00:00

Overwhelmed solo seniorWelcome to season 4, episode 7 of the ALiEM Medical Education in Cases (MEdIC) series! Our team (Drs. Tamara McColl, Teresa Chan, John Eicken, Sarah Luckett-Gatopoulos, Eve Purdy, Alkarim Velji and Brent Thoma) is pleased to welcome you to our online community of practice where we discuss the practice of academic medicine!

This month, we present a case of an emergency attending who questions the common consultant call-etiquette of not contacting attending physicians to provide back-up on a busy call shift.

MEdIC: The Case of the Solo Senior

By Dr. Kaif Pardhan

It was a busy night at Willow Wind Hospital, a large academic teaching centre. Sheila, one of the staff emergency physicians, was just finishing up her evening shift.  She quickly looked up at the clock above stretcher #10. It was just five minutes before midnight handover; just enough time to complete her last duty of the night:  Consulting the internal medicine resident for an admission of a hypoxic elderly woman with community acquired pneumonia.  

It was a slam dunk case in her opinion.  The patient had a room air oxygen saturation of only 85% despite several hours of treatment in the department. When she had initially arrived she had been hypotensive, delirious, short-of-breath and hypoxic. The initial septic work-up was complete, the patient had been appropriately resuscitated.  Antibiotics and fluids had been initiated, and hours after she had arrived, she was now hemodynamically stable.

Sheila located Jose, the PGY-2 Internal Medicine Senior Resident, in the emergency consult room. He seemed to be diligently typing up a consultation, but seemed quite frazzled. “Hey Jose, how are you doing? I’ve got a quick consult for you. It’s an easy one so shouldn’t take long!”

Jose was already stressed but hearing that he had yet another consult to complete was making him panic. His stomach was in knots and he could hear his heart beating rapidly in his chest. He had always heard that “The Willow” had a very busy internal medicine service and his first senior call was certainly holding true to its reputation! His pager started going off at precisely 5:00 pm when he started his senior shift and hasn’t stopped since. He’d already received 17 consults, not counting the 5 left over from the day team. Several consults still needed to be triaged and he hadn’t started reviewing with his juniors or medical students. He had just called his staff, Dr. Gupta, for the 11pm update. Not wanting to appear too needy, he told her everything was “going well”.

Jose sighed and resignedly grabbed his pen and his new consults sheet. He looked up at Sheila, and softly asked: “Can this consult wait a few hours? It’s been crazy and I haven’t started reviewing the prior consults yet… and I still have several consults to triage.”

“Sounds like you’re having a rough night,” Sheila responded, notably concerned. She could see Jose was overwhelmed and very stressed.

“Yeah, I have never had a call shift this busy before,” replied José.

“Have you called your staff to come in for back-up?”

“I just got off the phone with Dr. Gupta… It’s fine. I can handle it. Just give me the consult.”

“Well, is she coming in to help out?” Sheila was a good friend of Mindy Gupta, the staff internist on call.  Mindy was a rockstar educator, and there was absolutely no way that she wouldn’t be right next to José slugging it out if she knew he was drowning.  Everything seemed off.  “Hey, you know I went to school with Dr. Gupta, I can text her for you if you’d like?”

“No, please don’t. I’m fine. So what’s the consult? I have to get moving!”

Discussion Questions

  1. Whose responsibility is it to activate the back up for the Senior resident? Whether that be in the form of the staff or back-up senior resident?
  2. What role does the emergency department play in making sure that consultant services are not overwhelmed on busy nights?
  3. How might we create the conditions for senior residents in the hospital to be successful in managing large case loads? And how do we prepare them to take on this responsibility as they transition into independent practice?

Weekly Wrap Up

As always, we will post the expert responses and a curated commentary derived from the community responses 2 weeks after the case is published.

This month, our 2 experts are:

  • Dr. Lindsay Melvin
  • Dr. Alim Pardhan

On May 12,  2017 we will post the curated commentary and expert responses to this case! 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.

MEdIC Series: The Concept
Tamara McColl, MD FRCPC MEd(c)

Tamara McColl, MD FRCPC MEd(c)

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba
  • GIM Senior

    This is a great case. As a senior internal medicine resident, I have frequently felt overwhelmed on call shifts due to the number of consults I have received. There are usually several issues at play:
    1) A resident’s desire to prove him/herself to an attendings and show them that they can manage a busy call shift. This is particularly true when attendings often talk about how busy they were as residents and never bring up cases where they had to ask for help, making residents feel that they will have failed if they do need help. It’s also made worse when they hear about other residents managing these situations and brushing them off as not being stressful or challenging, enhancing a feeling of failure if they feel like they can’t manage it. It creates a culture of fear, and is made more difficult by the fact that you get an evaluation every 4 weeks and things like making your staff come in may affect that.
    2) Concern about activating the backup resident on call (after all, no one wants to be called at 9 pm and told to come in to do work, and you feel responsible for your colleagues’ well-being) and fear of calling the staff for the same reason (i.e. wanting to protect them, etc.)
    3) Culture created in academic hospitals where the attendings don’t seem to be expected to do clinical work and many are averse to doing consults or seeing patients
    4) A desire to see if, as the resident, you can handle it and manage everything overnight because we know that in the community, things are as busy if not busier. Sometimes a difficult night is a chance to prove to yourself that you have what it takes.

    There are also a number of issues that contribute to how stressful a night is that depends a lot on how the ER physician on duty manages things. Some of the things that make it more stressful are:
    1) Having multiple referrals come in all at once. There’s nothing worse than feeling like you’re a bit behind or even caught up and having someone come in and give you 5 consults. Being given consults over time instead allows you to have a bit more control over your time.
    2) Having an ED physician who has a low threshold for referral. There’s nothing that makes for more work than a referral overnight for a patient who could have been discharged from the ED. Even a simple question (e.g. is this WBC count worrisome? Am I missing something in this patient with chronic pain who has the same chronic pain now?) will generate hours of work if the patient can go home. Rapid referral clinics have helped hugely with this, however, but not everyone uses them appropriately.
    3) Having a culture where on ED physician can’t hand something over to the incoming ED physician that requires management. I’ve had patients referred for CHF where they literally received 1 dose of IV Lasix and totally turned around. But because the referring physician was leaving, they didn’t want to burden their ED colleague to check up on the patient and instead referred to the resident.
    4) The power imbalance of having an attending ED doc refer to a resident who can’t say no to a consult or refer the consult back to the ED if they find out the consult was inappropriate or needed to go to another service- or could simply go home (e.g. the classic “patient can’t walk, but I didn’t actually try to walk them”- and then finding out that the patient can walk but you can’t refer them back…).

    I think the system needs to be worked on from both directions:
    1) There should be automatic numbers at which the backup resident or attending is required to come in, effectively taking discretion about what the senior can/can’t handle away from the resident on call. The reality is that it’s a matter of patient safety, and a bunch of non-patient factors shouldn’t affect coverage.
    2) There need to be rules about how patients are referred to all services and recognition from the ED about what is and isn’t appropriate as a consultation. There also needs to be recognition of the power dynamic between the ED and consult services. Finally, there should be rules about how consults are delivered (for instance, I don’t believe that the ED physician concurrently saw 5 patients and everything just came back right before handover and now they have 5 consults to give you and are leaving, with poor documentation and stories that don’t match up with no way of clarifying anything cause the ED doc is now gone).

  • Stella Yiu

    Great case for discussion, and an increasingly relevant one as there is more hospital overcrowding and increasing patient complexity.

    Thoughts on the first 2 questions:
    1. The threshold of ‘needing help’ would be different for each senior resident, depending of what he/she has on the go and what team is on that night. In an ideal world, the resident would recognize this threshold is met, and the staff should be called. However, that is not always the case since the resident might feel it is a sign of weakness/inexperience to call, or felt he/she should be able to have a handle on it once task X or Y is done and so ‘the staff does not need to be bothered’.

    2. I am not sure if I have the answers but I have a recent experience. During a busy shift there were 7 consults to a service within a short time span. My EM resident identified that the resident was clearly overwhelmed. The staff has not come in. We sat down with that resident aside and discussed the plan to see these patients. I said specifically that ‘you should call the staff in since the wait times are long. It is not your fault that there are a lot of consults’. I also said that ‘tell your staff that the Emergency staff made you call’. In the end, the staff came in and stayed for 4 hours just to see the consults. I think us 1) giving permission/suggestion to call and 2) shifting the responsibility to the Emerg staff physician were helpful. It also helped that the staff was really wonderful. Just had no idea the resident was overwhelmed.

    • Tamara McColl

      Thanks for sharing your thoughts, Stella! I like your suggestion of shifting responsibilities to the ERP – will definitely make it easier for the resident to ask for help. I’m curious as to what kind of guidelines our various consultant services have in place far activation of back-up while on call… perhaps a more concrete plan of “once you’re >5 consults behind, activate back-up” would be beneficial and take the stress off of the resident to make the call.

    • Eric Wooltorton

      Thanks for the invitation to join the conversation Stella! What a great case and oh so familiar. I’m coming from the perspective of the staff supervising the senior and I agree with having the ER doc activate the back up system and take the ‘blame’. It’s in no one’s interest to have the senior get slammed too hard. In the end patients will pay the price. ER flow will stop. And frankly from the inpatient staff perspective I will still find out about sick pts. But not until 3-4 am.

      I’m always intrigued by the balance of learners seeking the chance to demonstrate performance with the competing pressure to learn and receive feedback (or in this case support). As a staff I try to balance my need to keep things running smoothly with their need to demonstrate autonomy and self regulation.

      Final thoughts: our work cultures are ones we create are perpetrate. Even unhealthy ones. We need to sometimes step in to ‘be the change we wish to see in the world’. None of us appreciate burned out residents. And if our helping out as a staff person can prevent that, great. I set the rule at the start of the shift that they are to contact me BEFORE they are under water, not after.

      Great discussion!
      Eric Wooltorton MD Director of Faculty Development uOttawa Department of Family Medicine

      • Tamara McColl

        Thanks for posting Eric!

  • Therese Mead

    1. Overall, it is the responsibility of the senior resident to own up to his/her limitations and know when to ask for backup. This should be discussed with the resident well before the first night of senior call – it’s ok to call in backup if you’re overwhelmed and putting patient care at risk. I’d continue the conversation with the internal resident, perhaps framing the discussion to emphasize that the staff would definitely want to be aware of the situation and might in fact be upset if the resident did not notify of the situation.

    • Tamara McColl

      Great comment on framing the concerns of the ED staff. Does your centre have guidelines for activating backup call to make it clear for the senior residents? Or is it more of a case by base basis – guidelines set by the staff on call?

      • Therese Mead

        I am not aware of any specific guidelines at my institution

  • I’m looking at this from a slightly different perspective of a paramedic, and from having worked with our local hospitals on our triage and transfer of care process.
    Look at any system that provides backups or additional resources when practitioners are overwhelmed (eg: triage RN with multiple paramedic crews needing to give report or on offload delay) – if your system relies on that practitioner to recognize the situation and decide call for help *all while overwhelmed* then you don’t have much of a system, and the system is not likely to succeed.
    A robust escalation plan needs automatic check points or notification points: “If x many crews waiting to triage, or 1 crew waiting >30 mins, MRN notified. If waiting >60 minutes, department manager and Paramedic Superintendent notified.”
    Taking the decision out of the overstressed individual’s hands by putting a system in place with clear guidelines also helps fight back against a culture that makes providers think they’re letting their team down when they need help.
    Just some food for thought from another area of the healthcare world.

    • Nick Johnson

      I agree with the above commenst. This should not be entirely the responsibility of the ED, but it’s up to all of us to create a culture in which calling for help is acceptable and expected, especially when patient safety is at stake. As someone who also attends in the ICU, I’ve learned to do the following to encourage and normalize off-hours communication: 1) create transparent expectations of when to call. I have a day 1 spiel that includes “it can get extremely busy on this service, and it’s typical that residents will need back up, especially at night. please call me for x,z,y or if you’re feeling overwhelmed by either acuity or volume. As one of my mentors said ‘I never wake up mad’ and would much rather be awoken at night then surprised in the morning.” And 2) we should also routinely check in. I often electronically follow sick patients from home, occasionally check in with charge and other nurses, and routinely check in with housestaff to ensure that all parties understand that communication is expected and normal. Lastly, if a colleague (in the ED or elsewhere) noticed that my resident seemed overwhelmed, I would certainly want to know.

      • Tamara McColl

        Thanks for posting Nick! Really like your approach to your on-call learners! Do your colleagues follow this same mantra?

        • Nick Johnson

          It’s definitely not universal among my colleagues, but was a practice that I learned from several of my mentors when I was a fellow at the same institution and adopted. It certainly is not the case here for all specialty groups; we too have a long way to go.

        • Nick Johnson

          One other point worth noting is that some critical care groups (including mine) and internal medicine groups have hired nocturnists (or noctensivists, as we call them) to have a 24/7 staff or attending-level presence in the hospital. While this practice has not been proven to confer a benefit in patient-centered outcomes (PMID: 23688301), we have found that it helps with patient flow and allows for additional teaching opportunities at night while perhaps sacrificing a bit of resident autonomy.

    • Tamara McColl

      Great insights Josh! Thanks for posting. Agree with the need for some form of an escalation algorithm in order to remove that additional stressor for the learner. Curious as to why this doesn’t exist broadly, particularly with continuously growing emergency patient presentations and admissions over the last several years (numbers that will only continue to grow as our population ages)!

    • John Eicken

      I really appreciate and agree with the comments by both Josh and Nick. Having objective check points, similar to those mentioned by Josh, are very important to remove the subjectivity associated with having a stressed and/or overwhelmed resident be expected to reach out to his or her supervisor and eliminate the inherent forces at play with asking for help from a senior or supervising physician (i.e. being perceived as “weak”). In this case objective check points could include a particular number of consults the resident is behind on or the amount of time it is taking for the resident to give consult recommendations/disposition from the initial time of consultation. As Nick mentioned, setting expectations from the beginning is important as well. Although I only practice emergency medicine (and do not supervise off-service consultants) the quotes “I never wake up mad” and “would much rather be awoken at night then surprised in the morning” really resonated with me and I think parallel my strong preference that residents notify me early when they are stressed, overwhelmed, or concerned about something in the Department rather than wait until a bad outcome occurs which impacts patient safety. I’m curious if anyone has experience in a Department where objective measures were successful in activating back up clinical support for consultants working in the ED?

  • It seems the Emergency Department often ends up picking up the slack for many deficiencies elsewhere in our healthcare system – why should it be added to the EM physicians’ overwhelming list of on-shift responsibilities to be the safety valve for other services’ staffing and supervising inadequacies? After all, as EM physicians we would not expect to rely on other services to come tell us that our own senior EM residents are overwhelmed on shift – as supervisors WE should be on top of that!

    The knee-jerk reflex to this issue is to blame the resident, questioning why he/she didn’t ask for help from a staff who’s off-site…but to me, this is as much (or more so!) on the shoulders of the supervising staff as it is on the resident. It reflects a problem with providing a safe and adequate supervising environment – it is the service staff’s job to proactively ensure that his/her learners are operating effectively and safely, perhaps checking in regularly to keep a pulse on new consults and workload, etc.. You simply cannot just assume the resident would have significant insight as to when to ask for help.

    • Tamara McColl

      Thanks for posting Ed! You bring up excellent points regarding where the responsibility lies. Unfortunately we often feel the effect of this type of situation in the ED as patients sit in the department for prolonged periods of time and admission decisions are delayed (particularly an issue in centres who do not follow the one-way consult culture). Do you see a role for emergency in helping to change this culture?

      • Absolutely! But not ideally at the frontline on shift. This is one of those issues that strong EM leadership and advocacy is required to have meaningful change; this includes in the board room of hospital senior admin, MAC, etc.. there is no way that frontline EM physicians can reliably know what each consultant service residents have on their plate when on-call (ie on the wards, on the OR list, etc)… by the time we do notice an overwhelmed service as evidenced by delayed consults in the ED, it is TOO LATE. Our most important role is to advocate for system changes that puts the responsibility back on the supervising staff consultants, and proactively preventing these types of situations!

    • McCoy Robins

      Thank you Ed and Tamara for your insight from the perspective of emergency physicians. It would be remiss of me, however, if I did not add the opinion of consultant residents to this discussion. I am a radiology resident in a mid-sized western Canadian city. In addition, I have numerous colleagues and friends in resident consultant roles across both surgical and medical specialties. The problem of consultant overload is multifactorial however no one has yet addressed the issue of inappropriate consultation and imaging by the emergency department.

      At our institution, a significant contributor to consultant-overload (and the potential need to call in staff) actually lies first and foremost with the emergency department. The inappropriate use of the consultant teams and radiology department by the ED is pervasive and only results in greater back-logs in the system. As an example, medicine residents are not infrequently consulted without any significant form of a history, physical, or work up. It is nearly a weekly occurrence already that consultants are called before a patient is appropriately resuscitated or stabilized in the ED. Necessary procedures or interventions are often omitted. These factors serve to only increase the time a consultant resident has to spend with each patient and further slows down their work and progress.

      The radiology department, for instance, images patients directly from the waiting room, with the patient having been assessed only by a triage nurse and never seen by an emergency physician. We often are asked to image patients before blood work or primary imaging returns – difficult to ascribe shortness of breath to a pulmonary embolus without a chest X-ray or white blood count. And finally the number of inappropriate tests (Wells score 0 CT pulmonary angiograms) or non-emergent cases (malignancy work ups) performed from the emergency department only increases year by year.

      This speaks to the increasing use of consultants and imaging as the primary “history and physical” of many emergency physicians. Emergency physicians that focus solely on disposition rather than treatment often unload 8-10 patients onto the radiology or medicine resident at sign-over. From a consultant point of view, there is absolutely no way to predict or manage these “consult boluses” – we are doomed to fail before even starting. Although consultant residents are doing our best to keep up, we need emergency physicians to play an active role in the care of patients rather than acting as glorified triage nurses.

      It is apparent that the culture of over-consultation and over-imaging is at least partially attributable to inadequate training, education, and experience of emergency residents. I cannot speak for all institutions, however I can say that at my institution emergency residents put in only a fraction of the hours that residents of other consultant specialties do. In our radiology program, for instance, residents are in-house 70-100 hours per week between clinical and call duties, with the expectation to read an additional 15-25 hours per week at home. My colleagues in medical and surgical specialties have similar hours and expectations. Comparable-level emergency medicine residents are regrettably working an average of 32 hours per week (sixteen 8 hour shifts per 4 weeks). This is simply not enough time to develop the skills required of a specialist physician and it is this lack of expertise that contributes to over-consultation and imaging. From experience, a knowledgable emergency physician increases throughput by minimizing imaging and consultant time.

      The emergency department plays a valuable role in the medical system however this discussion has been somewhat short sighted. Thought, judgement, and insight are required by our emergency medicine colleagues before consulting or imaging. It saves the health care system time and money. By reducing the burden on consultant residents, it frees up time to manage the truly acute and unwell patients. In the end, if emergency physicians went through more robust training and practiced more thorough medicine, I doubt we would even be having a discussion about calling staff in for backup.

      Warm regards,

      McCoy Robins

  • Heather Nicole

    Thanks for putting together a great case. As a senior Internal Medicine resident, there are definitely elements of this scenario that I can relate to.

    QUESTION #1: I agree with much of what has been said already re: activating back-up. Having set guidelines about when to call in help, for example when there are X patients waiting to be seen, can serve as a useful trigger for the senior resident and hopefully make it seem more objective and less like a personal failing. Having said that, there needs to be nuance – two sick patients might actually be a better reason to call in back-up than six otherwise stable patients. At our institution, the Medicine senior receiving consults is expected to contact the Chief resident on-call if things are getting crazy, and they review the situation together to see whether the back-up senior resident needs to activated.

    As to whether the ED staff should be responsible for activating back-up, I think that ideally the ED staff would encourage the Medicine senior to think about calling in help – or at least letting the Internal Medicine staff (or chief resident) know what is going on – rather than go over the senior’s head. Having said that, if patient safety is being compromised and the Internal resident is not recognizing this, then the ED staff should definitely be contacting the Medicine staff directly.

    QUESTION #2: The natural ebb and flow of consult volume in the ED means that even with good back-up systems in place, there will always be times when patients will not be able to be seen immediately by the consulting service. As the Medicine senior, I’ve found it extremely helpful when the ED staff or resident agrees to co-manage the patient until someone from the Medicine team is able to begin the consult. Even when I have not asked specifically, the ED staff I have worked with have often been good about following up on bloodwork and letting me know if there has been a change in the patient’s condition.

    QUESTION #3: Managing incoming ED consults has probably been the most harrowing part of being a Medicine PGY-2. There is definitely an art to it, and while I still have so much to improve on, it does get easier with experience. There is also only so much that can be prepared for in advance. With the advent of CBME and the move towards more direct observation, I believe we should be having staff (or PGY-3s) observe new PGY-2 accept, triage and manage consults and provide feedback. I think it would also be helpful for the PGY-2s receive feedback from the ED staff giving the consults. Finally, as has already been said, it is important that we create and foster a culture where asking for help is not seen as a sign of weakness, but rather as the mark of a professional who recognizes their limitations and prioritizes patient care.

  • MelodyO

    I think it is very staff and service-dependent as to which staff physicians will come in and help the resident out. From my off-service experiences, I would say few staff physicians will come in and help the resident out. Similarly, I have seen few residents, including myself rotating on other services as an off-service resident, call in the staff physician for back up. As mentioned in previous comments, every resident’s threshold for ‘needing help’ is different. Calling in for help or back-up may be perceived as a sign of weakness or incompetence. The only times where I have seen my colleagues or myself call in for back-up help are ethical or critical life-or-death situations. Or if the staff physician explicitly says before he or she goes home, “Please call me ANYTIME”. I don’t know what the best solution is, but I do think if we could change the culture or atmosphere to make it easier or more inviting for senior residents to call their staff physician for back-up, then they would do so more often.

    In Winnipeg, having rotated as IM ward senior and IM consults service, I know that it can become over-whelming being the only senior IM resident on for the entire hospital, especially from 1900 to 0700. And especially as an off-service ER resident who does not know the IM staff physician at all (many times I reviewed patients over the phone to a face I had never met before), at times, it may have felt uncomfortable for me to ask for back-up help (thankfully I was never ‘slammed’). This applies to any off-service resident rotating on X Y Z service (i.e. family medicine resident rotating on orthopedics). Bottom line, I think it has to start from the top, eliminating the rigid hierarchy, and allowing residents to see staff physicians as their colleagues, which I think is better exemplified in ER; I do not fear having to ask for help when needed.

    • Tamara McColl

      Thanks for sharing Mel! You’ve given us a lot to think about!

  • Heather Nicole

    Thanks for putting together a great case. As a senior Internal Medicine resident, there are definitely elements of this scenario that I can relate to.

    QUESTION #1: I agree with much of what has been said already re: activating back-up. Having set guidelines about when to call in help, for example when there are X patients waiting to be seen, can serve as a useful trigger for the senior resident and hopefully make it seem more objective and less like a personal failing. Having said that, there needs to be nuance – two sick patients might actually be a better reason to call in back-up than six otherwise stable patients. At our institution, the Medicine senior receiving consults is expected to contact the Chief resident on-call if things are getting crazy, and they review the situation together to see whether the back-up senior resident needs to activated.

    As to whether the ED staff should be responsible for activating back-up, I think that ideally the ED staff would encourage the Medicine senior to think about calling in help – or at least letting the Internal Medicine staff (or chief resident) know what is going on – rather than go over the senior’s head. Having said that, if patient safety is being compromised and the Internal resident is not recognizing this, then the ED staff should definitely be contacting the Medicine staff directly.

    QUESTION #2: The natural ebb and flow of consult volume in the ED means that even with good back-up systems in place, there will always be times when patients will not be able to be seen immediately by the consulting service. As the Medicine senior, I’ve found it extremely helpful when the ED staff or resident agrees to co-manage the patient until someone from the Medicine team is able to begin the consult. Even when I have not asked specifically, the ED staff I have worked with have often been good about following up on bloodwork and letting me know if there has been a change in the patient’s condition.

    QUESTION #3: Managing incoming ED consults has probably been the most harrowing part of being a Medicine PGY-2. There is definitely an art to it, and while I still have so much to improve on, it does get easier with experience. There is also only so much that can be prepared for in advance. With the advent of CBME and the move towards more direct observation, I believe we should be having staff (or PGY-3s) observe new PGY-2 accept, triage and manage consults and provide feedback. I think it would also be helpful for the PGY-2s receive feedback from the ED staff giving the consults. Finally, as has already been said, it is important that we create and foster a culture where asking for help is not seen as a sign of weakness, but rather as the mark of a professional who recognizes their limitations and prioritizes patient care.