onthewards is an initiative created and independently run by junior doctors for junior doctors and medical students, dedicated to delivering free open access medical education. Avant has partnered with onthewards as part of our strategic partnerships program. Avant and onthewards work closely together to develop risk management content specifically tailored for junior doctors. This blog post was originally published by onthewards. It has been republished with the permission of onthewards.
‘The reality is medicine is a team sport and there is always someone to talk to and most importantly, the aim of the game is to deliver the best outcome for the patient3’ ~ Abhi Pal
In starting my internship I came to the sudden realisation that I’m now a doctor. I now have responsibilities and I have to know stuff. Like really know stuff, including how to do my job properly.
One of the most daunting things about graduating medical school and starting an internship was the prospect of not knowing what to do and having to ask for help. I felt like the act of asking for help was, by default, an admission of inadequacy, unpreparedness and of being some kind of impostor who never should have graduated.
I’m sure orientation into internship is different for every hospital. Luckily mine had a strong focus on where to go for help and that asking early and getting too much help is always better than not asking at all and something going wrong. Phew, what a relief! But still, in those first few weeks I had to be convinced that picking up the phone and calling someone (who is literally rostered on to help) was the right thing to do.
Why is it ingrained in us that asking for help makes you inferior?
Studies have found that barriers to escalating patient care include perceived issues accessing more senior staff, lack of judgment about when to seek help (also known as situational unawareness) and concern about negative responses from senior staff1. Personally, I was mostly worried about negative responses and being dismissed or reprimanded for not managing a task independently.
I started my internship on relief term. Relief term is notoriously difficult and without asking for a lot of help, completely insurmountable. I can’t count the number of times I had to phone a friend for help with a cannula. I’m better at it now but definitely not 100%. But it’s okay because I have seen peers more senior than me ask for help with cannulas too. Sometimes they are materially difficult.
Asking for help – the right thing to do
There have been plenty of situations where I’ve felt out-of-my-depth in managing a patient’s care. For example, on night shift reviewing a surgical patient who was unresponsive but otherwise haemodynamically stable, I was unsure if they had suffered a stroke. In this situation, it was essential I call for help. I needed someone else to corroborate my examination findings and determine how extensively he needed to be investigated. Continued assessment found he had a hypoactive delirium and I was satisfied that getting advice early was the right thing to have done.
There were also situations where, in hindsight, I probably could have managed on my own. I remember being asked to confirm a PICC line position on chest x-ray. Mostly I can determine the position but still the risks of administering medications through a line in the wrong position outweighs the concerns I might have about asking someone more senior to confirm my assessment.
I feel this is a core part of supervision and training where the process of reassurance about your initial assessment means that in the next similar situation (or the next, or the one after that) you will be happy to see it through independently.
Asking for help differs across scenarios and clinical structure. As found by Kelly et. al., junior doctors may perceive that senior help is unavailable or inaccessible. A study looking at influences on junior medical staff in decisions about seeking clinical support describes the phenomenon of junior doctors ‘saving’ questions to ask when a supervisor is more available because they feel these questions do not justify a specific phone call2. In settings like the emergency department where multidisciplinary and multi-seniority staff are all working closely in the same area, with easy access to each other, seeking and receiving help may be easier.
You need help as often as you need it
Asking for help should be easy. Junior doctors should feel supported and confident that they are practicing safely. In my experience, I feel this is the case. But I think I am lucky there’s a strong emphasis on supporting junior staff at my hospital. It’s something that needs to be ingrained in the culture of the staff.
One of my best experiences of this was during my obstetrics term. The other residents and I agreed from early on to help each other and provide assistance whenever we were able, so we were all working for a common goal and viewed the workload as something to be conquered as a team.
Asking for help is important but nonetheless it can be daunting. People often talk about negative responses they’ve had when asking for help and it’s difficult to gauge how often it’s appropriate to ask for help. What I’ve learned is that really there is no magic number; you need help as often as you need it. Every shift is different and most often in internship you’re in clinical situations you either have never seen or have had very little exposure to. It is inevitable you’ll need help during your internship and the good news is you can prepare for it.
A useful starting point is to practice ISBAR
ISBAR stands for ‘identify, situation, background, assessment, recommendation’. It frames the situation, the patient and relevant information in a way that’s easily understood by the receiver. And like all clinical skills, using ISBAR as a way to frame your discussion with a senior colleague takes practice.
These are some strategies I have found helpful:
- make your situation clear and have a summary sentence prepared about it. From the start frame what you need from that person (for example, do you need advice, help with a procedure, or someone to come right away?)
- have information about the patient at hand, including notes and bedside chart
- pre-empt what kinds of follow-up questions might be asked ( for example, a full set of observations)
- be polite! Say thank you when you get the help and if you have time observe what they do so you take the opportunity to learn a new strategy or approach to something.
Although it’s easy to feel inadequate when needing help, ultimately you are keeping patients safe by seeking senior guidance.
Internship should be filled with teaching, supervision and learning
Internship is part of your training. One of the best things you can do now or at the beginning of your internship is to practice handing over or talking about clinical situations in the ISBAR format with peers and supervisors and getting their feedback.
In medical school there is a large focus on communicating with patients but communicating with peers is also an essential skill. For example, doing a consult for your team is a form of asking for help. Especially when the issue is not in an acute or critical setting you can get indirect feedback from the receiver by their responses to the information you have given and direct feedback from your seniors by asking them to listen to you.
It’s important to remember your knowledge and skills will improve exponentially in your early training, most often from asking for help, and this all contributes to shaping your clinical identity and independence.
More on ISBAR
ISBAR, SA Health
Clinical Handover, Clinical Excellence Commission
More about onthewards
Onthewards is a free open access medical education website designed for prevocational doctors. Onthewards was set up to address the gap in formal education specifically designed for, and aimed at, intern doctors. What started as podcasts for junior doctors at Royal Prince Alfred Hospital grew into a website available to everyone after doctors in other hospitals expressed their interest.
1.Kelly, Larwill, Hamley& Sandford. (2014). Failure to escalate: what stops junior doctors asking for help when they need it? Asia Pacific Journal of Health Management, 9: 3
2. Kennedy, Regehr, Currie, Baker & Lingard. (2009). Preserving professional credibility: grounded theory study of medical trainees requests for clinical support. BMJ, 338:b128
3. Call me if you need me. But remember – it’s a sign of weakness by Abhi Pal
This blog post has been republished with the permission of onthewards. Avant is not responsible for the accuracy of any information contained in this post.
Share your view
We welcome your feedback on this article – email the Editor at: email@example.com