Wednesday, December 17, 2014

Please answer this question

At a meeting this week of the MedStar Health patient and family advisory council, Rosemary Gibson and Anne Gunderson asked,

"As a patient or family member in a hospital, what are your assumptions and expectations with regard to medical students and residents when it comes to patient safety?"

Please think about that for a moment, and post your answer as a comment here.  (I'll respond afterwards.)


Andrew Tarsy said...

From Facebook:

Assumptions and expectations are, first: that they have high level of training for what they are asked to do and that safety, privacy and patient dignity are important parts of that; and second, that they are supervised both by medical professionals and also some sort of programmatic supervisor who is ensuring they are complying with the program, etc. I hope I am not too far off.

Victoria Nahum said...

From Facebook:

I assume they are being properly supervised and appropriately guided, always following best practices. I assume I am not the 1st patient they perform XYZ procedure on. I assume they are well-rested when they care for me. I expect I could be wrong in all of these assumptions.

Anne Marie Cunningham said...

My own thoughts- with regards to medical students I would expect to explicitly give consent for any medical student to speak to me or to perform a procedure on me. If there were performing a procedure then I would expect that they woukd be adequately supervised.
With regards to residents, as with any doctor, I would expect that they were working within their frame of competence. Whilst training I would expect them to be adequately supervised.

pheski said...

I expect them to:

*Explain their status and tell me who supervises them and how. (E.g., "I am a second year family practice resident. After I make these work rounds with you in the morning, I present my findings and plan to our attending, Dr X, and my fellow residents. Dr X and her coverage are available any time you or I think we need them.")

*Be directly supervised or indirectly supervised based on their level of training and experience.

*Ask me for feedback: "How am I doing as a physician in training? Are there things I do well or things I need to work on?"

*Be comfortable saying "I don't know. I'll find out and we can learn about it together."

Anonymous said...

I would expect that there's someone around who is accessibly that the trainees could turn to, with immediacy and in-person, when they're in over their head. And, I'd expect that that person would be around sufficiently to recognize when a resident or med student is in trouble with regard to understanding what's happening with a patient, even if he or she does not.

Emily said...

I suspect that most patients will never know if the doctor treating them is still in training. Even though they have many years ahead of them before being licensed to practice independently, they have MD behind their name and legally can identify themselves as such without qualifiers unless asked (I think). If the patient does suspect something because the doctor may look really young, or not exude confidence, many patients will be polite or too timid to probe so as not to offend.

Anonymous said...

expectations: 1)that they or their supervisor will identify themselves as a medical student, even though introduced as 'Doctor', . 2)that their training is a systematic, tested, and reviewed process, as evidenced by defined skills, knowledge, and abilities. 3) that their clinical supervisor knows them well enough to have confidence in their ability to practice the given KSA, 4) that their supervisor is on the floor and immediately available to them.
Assumptions: that all or some of the above are not the reality.

Hilary said...

That residents, medical students -- and anyone in the hospital -- are empowered to speak up if they see a patient safety issue. More fundamentally, that they are supported by faculty and a hospital systems which make patient safety a priority.

Peter said...

Responsibility for safety concerns should be commensurate with student level of responsibility in delivering care. With a critical caveat: If you don't know...ASK, and keep asking until you get an answer. It should be an answer that you understand well enough to explain to a family member who is scared to death, knows nothing about medicine, and doesn't trust you very much in the first place!

During my training and while teaching med students, there were two kinds of student involvement. One was standing at attention against the wall while the attending, fellow or resident led the parade--and was responsible for all care decisions. The kid was a qualified observer, nothing more. He could answer questions about safety with the caveat that they be reported to the Boss Doctor with dispatch.

The other was VERY different. The student had responsibilities ranging from venipuncture to total care.

to wit: When I was a 3d year student on surgery, my resident led me to a comatose, 300 lb chicken plucker who'd been unconscious in her hen house for 3 days with dead bowel in her belly. He said, "Fix 'er, Doctor!" I spent 16 hours every day for 2 months learning from that lady. She walked out of the hospital. Her sister was with her in ICU once an hour-every hour-during her the patient's stay. When the sister was scared, I was "it" for answers, including "I don't know. And I've asked those above me. They do/do not know either." It's about the oath we all took.

The point is, nothing approaches understanding of the ethical truths and nuances of a patient's care like the crucible of responsibility. A patient's care can be and often is VERY different from patient care.

Bart Windrum said...

From Facebook:

I assume that they're better oriented toward safety since they're newly trained. But I'd ask to verify that assumption because I try not to expect one thing or another except to have always to do the hard vigilant work of patient-family advocacy 24/7/365. I'd also assume that they're horribly overworked and under-slept.

Alex Warren ‏@alexfwarren said...

From Twitter:

I wonder how many of us (med students) would know the best way to report concerns/adverse incidents we encounter...

Naomi Kaufman Price said...

I assume nothing. I expect adequate supervision and training, but I certainly don't assume it.

Kim said...

I would want them:

To be supervised.
To wash their hands in front of me (or family).
To tell me who they are, their level of training/experience and their role in the team.
To be respectful.
To be honest.
To be kind and compassionate (we don't want coldness masquerading as professionalism).
To ask how I would like to be addressed (not the common assumption that everyone is best friends on first name terms).
To communicate regularly and openly.
To know their limits and to seek help whenever needed.
To think carefully and logically about what investigations are needed so that only those necessary are done.
To listen to me. (Patients are good observers even though their interpretations of what they observe may be wrong. Ignoring the observation because the interpretation is wrong can be as dangerous as tossing out the baby with the bath water.)
To learn from the experience.
To spare me unnecessary pain.
To get me out of hospital as soon as possible.
To ensure my after hospital care is coordinated if that is part of their role.

Nancy Thomas said...

I want them to see me not as a case to study, but as a human being. I need them to listen to me and leave their assumptions at the door. When I am sick and hurting I do not want to see them huddle with their supervisor at the foot of my bed and "discuss me" - but if they do, when they all nod their heads and begin to leave, don't just say good-bye to me - tell me what you now want to do. I also welcome their young eyes and fresh look at medicine and I hope they learn to speak up, make suggestions, etc. If it is a family member that is hospitalized, and I am sitting right next to that person, please don't ignore me. We know you know how to listen to a heartbeat and to wash your hands...we get that you know how to say 'good-bye' when you leave the room - but if we are allowing you to "study and learn" from us, then we are a team, here, are we not? Listen to our heart as well as our heartbeat. Finally, you will be the nicest looking, freshest, healthiest, newest person on the block to walk into our rooms on any one day. We are proud of you and we will help you if you also help us.

e-Patient Dave said...

I want them to
a) know what they're doing
b) be aware of risks, not in denial
c) follow documented safety procedures
d) welcome my questions (and my family's) and our attempts to help keep things safe.

An absolute requirement for me is that the hospital not have limited visiting hours. They must, gladly and without question, welcome my assistants' presence and contributions.

jberg said...

I would expect medical students to be identified as such, and to be accompanied by a supervisor. i don't think I'd expect that of residents.

Paul Hattis said...

One notion that I have not seen in the above posted comments (though alluded to by Hilary) is that there clearly needs to be a place to go (likely even anonymously) to report on patient safety issues that the student observes.

Reporting is not with a punitive goal, but with a goal of protecting patients and supporting quality improvement. The organizational system where the student is placed ought to support this ability to report without fear of retribution or negative consequences for the reporting student.

nonlocal MD said...

I am not sure why your question singles out medical students and residents. I would expect exactly the same from them with regard to patient safety as I would expect from their attendings or, indeed, any doctor - awareness and attention to safety best practices.
As for assumptions, again I would not assume anything different for docs in training - but then, I don't assume anything about doctors these days, even though I am a doctor.

Tom said...

Mixed. House staff is supposed to be supervised by the top docs in the hospital. This is fine. They provide onsite observation. However if supervision is lax, they can get patients in all sorts of trouble. I believe my choice would be to go without house staff and rely on my docs and nursing staff to take care of me and my family.

Pam said...

I assume that all students and residents are supervised by more senior staff, that everything they do is documented, that any decisions are corroborated, and that they are there to learn, help and assist -- not to treat on their own --- yet. I welcome their presence; I do not trust their judgment.

Kashif Sheikh said...

My expectations are no different than for a PA, nursing staff or physician. If a medical student is proficient in an area, I would expect them to proceed in patient safety maximizing behavior. If there is any gray area, doubt or question, it is incumbent on the student - and should be part and parcel of the learning process - to ask for clarification and education from an attending or other superior. Patient safety should not be about the individual practitioner but rather a process anyone can adapt to.

e-Patient Dave said...

I'll reply to my own comment above: I totally missed that this was about them being students or residents.

Yet, I still expect anyone who touches me to know what they're doing and be aware of risks and welcome my engagement on the subject.

Gene Lindsey said...

It is reasonable to expect that medical students and house staff would be taught and supervised to insure appropriate quality and safety. That is the responsibility of the attending.
How things are expected to work and what really happens probably varies frequently.

I would also expect that the system fails and when it fails it fails not only the patients who are harmed but also the medical students and residents who must deal with their own guilty feelings for having been a part of a process that did not deliver what was expected.

Tom DeSimone said...

My assumption is that they are properly supervised and trained meaning that when delivering care they understand when their decisions need confirmation by their supervisor before execution of same.