Working with and supervising residents takes a certain degree of trust. Empowering residents with trust can be a difficult proposition for educators. There’s a moment early in the career and education of an anesthesia resident where they earn the trust of their faculty and supervising attendings. This moment is not contingent upon the memorization of a textbook or the demonstration of intubation skills. It doesn’t depend on the recitation of facts or the preparation of a perfect anesthetic plan. This moment arrives when the resident can finally be trusted to recognize what they know and, more importantly, what they don’t know.
New residents may arrive in their program with a sense of bravado, having achieved great success at each stage of their educational career. If that bravado translates into false confidence, it can quickly become a liability threatening patient safety. As a faculty member responsible for supervising residents, there is nothing scarier than a resident who does not know when to call their attending.
Starting a career post-residency in private practice, in an organization where attendings mostly did cases on their own, I rarely worked with residents. This allowed me to hone my skills and focus on developing my personal preferences. I developed my own quirks and was generally free to practice as I saw fit. Consequently, when I moved to an academic center, I struggled to supervise clinicians, understanding that I needed to relinquish a certain degree of control to succeed in this new setting. What I did not immediately understand, however, was the importance of trust in our clinical practice. A plan for an anesthetic can be discussed and resolved. But what must be earned in short order by a new trainee is their supervisors’ ability to trust that they will contact them in a timely fashion when a question arises.
Six years into my career as an academic faculty member, I have taken to one critically important rule: I tell new trainees the first day I work with them. Call me for anything. I stress that I will never get mad at them for calling me, even for something trivial or perceived as such. I will only get “mad” if they do not call me, especially if their question turns out to have affected patient care in any way, even unexpectedly. I wish I could say that this rule and my emphasis on it have saved my colleagues and me from all adverse patient safety events. However, unfortunately, they still happen, and it is outside of my ability to prevent all medical errors.
Throughout my career, I have been either directly involved in, a party to, or made aware of numerous patient safety adverse events that could have been prevented by trainees who recognized their limitations or potential gaps in knowledge. There was the resident handed a vial of vancomycin, who pushed it rapidly via an IV line. A resident did not know how to administer mannitol and gave nearly three intravenous bags of it, for a total of more than 250 g in short order. Another resident did not know that dexamethasone and diphenhydramine came in vials that looked alike and gave 125 mg of the latter medication when intending to give 10mg of the former as a prophylactic for postoperative nausea and vomiting.
The waste of blood products is an incredibly serious adverse event that also causes regulatory and reporting issues in addition to compromising patient safety. So, when an anesthesia resident put cryoprecipitate and platelets on ice, rendering them damaged and unusable, I was even more disappointed to learn that this mistake likely occurred from a knowledge gap. This missing link was exposed because, once again, the resident did not know or recognize this gap and acted with false confidence and self-reassurance.
What do we do in this situation, and who has failed who? I would argue that faculty and trainees often fail one another. There are numerous factors at play in a situation where an unknown knowledge gap can lead to an adverse event that directly affects patient safety. Inherent personality characteristics can make one prone to false bravado and confidence that causes a resident to be unable to reflect and recognize one’s limitations. A competitive environment may lead to the perception that asking for help is a sign of weakness. An adversarial or inaccessible line of communication to one’s supervising attendings may cause fear of reaching out to certain faculty members on the part of a resident. So, what can be done to resolve this critically important issue? A three-pronged approach is necessary to address the potential breakdown of decision-making caused by not knowing what you do not know.
For trainees/residents, it is important to recognize, first and foremost, that we are “practicing” medicine and not “performing” it. If it were a performance, like a tightly choreographed Broadway musical, we would perform the same steps daily in every situation with every patient. Medicine is instead a practice in that it requires constant improvement and lifelong learning. We must understand that constant questioning is necessary to improve one’s knowledge and ability, and this process does not stop through residency, continuing in post-residency practice. Asking questions does not impute weakness; on the contrary, it shows a conscientious thought process in which a resident recognizes a potential knowledge gap, works to address it and seeks to close it to improve future patient interactions.
For supervising physicians, we must seek to create an environment that promotes collegial and collective educational improvement. Residents and trainees should be celebrated and encouraged to seek consultation whenever a decision may potentially affect patient care and when a trainee asks a question before charging ahead without the proper knowledge base. This is not to excuse inadequately prepared trainees or those who do not read textbooks or review charts in preparation for their cases. We should demand and expect the highest standards of our residents as we prepare them for independent practice. But in the process, we should strive to create the understanding that preparing an anesthetic plan and having your operating room set up properly may not preclude you from being handed a novel drug you’ve never before administered.
Finally, educational institutions and residency programs should educate supervising faculty and residents on the importance of communication and recognizing limitations. Expectation setting should be done early and often to stress the importance of patient safety above such concerns as personal shame or fears of appearing weak. It should be stressed that required educational conferences where errors are reviewed, such as morbidity and mortality rounds and quality assurance reviews, are done not to blame, but to learn collectively and avoid repeating past mistakes.
As a matter of fact, some of the greatest thinkers in human history stressed the wisdom in understanding one’s own limitations. According to Socrates, “Wisdom is knowing what you don’t know.” Confucius is quoted as having said that “To know what you know and what you don’t know, that is true knowledge.” Author Adam M. Grant says that, “If knowledge is power, knowing what we don’t know is wisdom.” In the practice of medicine, where every decision has the potential for near-immediate patient harm, it is more important than ever to stress that acknowledging limitations, and recognizing what we don’t know, is critical to the success of our patient care.
George Tewfik is an anesthesiologist.