Dr. Siegal maintained a dialogue with residents regarding the degree of supervision they needed. “A week into the rotation, I asked them how they felt,” he recalls. “Are you getting enough supervision? Too much? Most residents have a reasonable sense of what their deficiencies and discomforts are.”
Joseph Li, MD, director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center and assistant professor of medicine at Harvard Medical School, and Kenneth Epstein, MD, MBA, a hospitalist and director of medical affairs and clinical research at IPC-The Hospitalist Company, agree. Dr. Li, also an SHM board member, says not only are residents seeking the right amount of supervision, they’re also seeking the right type of supervision based on their strengths and weaknesses. He says residents also are looking for something else—a medical model. “I think they look for someone to model themselves after,” he suggests. “I think all of us do throughout life, sometimes on purpose but also without intending to do so to better ourselves and learn how to do things.”
Culture Change
Once an atmosphere rife with assigning blame for medical errors, teaching hospitals are changing how errors are found and disclosed, says Michael Lukela, MD, director of the pediatrics program at the University of Michigan and assistant professor of internal medicine and pediatrics.
“The focus is now on patient safety and looking more broadly at how medical errors come about,” he says. “The focus is shifting away from the individual while not overlooking the personal responsibility. There should be safeguards in place, which should prevent errors from occurring, so errors are not just about one person.
“Trainees want to know about the culture. What if they do make an error? Who should they talk with? Their attending? Many are fearful, but these fears don’t have basis. It’s based on what they experience in medical school, saw on TV, and learned from observing others.”
Instead, Dr. Lukela says residents should be saying: “ ‘I don’t understand how my patient got this wrong medication. How can we prevent that?’ It’s up to us as educators to step back and say, ‘That’s a great question’ and get them to think about why errors happen.”
Residents want to focus on the big picture—to learn the art of practicing medicine and get support to do what they need to do, says Dr. Amin. And attendings are looking for residents motivated to learn. “It takes time, energy, and motivation to teach—just like it takes time, energy, and motivation to take care of patients,” he says. “And the hospitalist is in the perfect position to do that.”
Hand-Off Errors
Although hand-offs long have been a part of hospital medicine, the ACGME’s recent resident work-hour limit has raised questions concerning its benefits and drawbacks.
“The concept of 80 hours [a week] is a very good one, but practically it has meant increasing the number of hand-offs,” says Dr. Lukela. “And when you’re increasing the number of handoffs, there’s an increased potential in increasing errors.”
To prevent errors, Dr. Amin says it’s essential to develop a culture around proper hand-offs. “Taking care of patients is not just about getting a history and giving patients drugs or doing surgery,” he cautions. “It’s also thinking about potential errors that can occur and minimizing them through the process of care.”
Dr. Lukela agrees, saying the key part of the hand-off that affects efficiency, quality of care, and error reduction is the thought process of the physician handing off. What is the patient’s history? What tests are pending? What is the action plan? And from day one in the hospital, he says, there needs to be a discharge plan so residents know what direction the patient is going in.