Art of Medicine: Gaining trust, and keeping it

Trustworthiness can be a hard concept to define. The Pediatric Milestones notes that it is;

The combination of clinical knowledge/skill, discernment, conscientiousness and truthfulness that allows supervisors and care team members to be more certain that the individual is responsible and capable of providing competent patient care without direct supervision.

In the Emergency Department we want to know if we can count on a resident to carry out a given task, make decisions or follow-through on any other aspect of clinical care in the ED with minimal or no supervision by the end of their training. Trustworthy residents are generally:

• Aware of their own limitations
• Conscientious (thorough and dependable in follow-through of tasks)
• Truthful

Many academic Emergency Departments rely on the provision of graded responsibility. That is, you get more the longer you are there. But time as a resident shouldn’t be the only factor. Certainly some R2s are more ready for autonomous decision making that others. In addition, undoubtedly there are multiple ways to supervise residents. Some supervisors are very hands-on and provide immediate course correction offering prompts and corrections to steer the resident into their line of thinking. Others supervise and provide oversight only during case presentations and then “check-in” on things after some time has passed, either via face-to face follow-up, or by checking labs, orders, speaking with nurses and other assorted methods of “backstage supervision.” In reality neither of the aforementioned styles is “right,” and the situation dictates which is appropriate. A coding child will require significantly more direction than a patient with a mild to moderate asthma exacerbation. Responsive oversight is practiced when the resident is allowed to raise issues requiring further clarification or escalation of care, while the supervisor provides backstage supervision and meters out increasing levels of autonomy based on their assessment of the job the resident is doing.

In order to effectively assess this milestone we suggest that supervisors:

• Review the patient care to-do lists constructed by the resident. make sure they are getting done what they say they are.
• Make sure residents know you are always available to help if they get in over their head. Some will avoid asking questions because they don’t want to bother you. Don’t mistake this for confidence!
• Know that some early residents are still “afraid to be wrong” as a consequence of their achievement based training in medical school. tell them it’s OK to not have all the answers and that teaching and learning is a highly collaborative (and rewarding) process.
• Use backstage supervision to cross-check/double-check data reported verbally by a resident by looking at orders, labs, notes, asking nurses/parents after discussing initially with trainee. But, if the resident repeatedly fails to get things done, omits, or worse – falsifies data be sure to supervise much more closely.
• Provide as much autonomy as you can within the confines of safe patient care by consciously avoiding the “guess what the attending is thinking” game whereby the resident makes decisions based on what they think you would do, rather than what they want to do. This is a bigger issue in large departments with many faculty that work varies shifts.
• Foster a culture where early learners are not pressured to be autonomous before they’re ready while allowing intermediate/advanced learners to cope with uncertainty. Make sure that the goals and objectives for the rotation are clear – and that both you and the resident understand them.
• Be transparent in your communication regarding how much autonomy you are providing in a given scenario.