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.
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
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
Why is it ingrained in us that asking for help makes you
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.
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
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
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
- 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
- have information about the patient at hand, including notes and
- 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
Although it’s easy to feel inadequate when needing help,
ultimately you are keeping patients safe by seeking senior
Internship should be filled with teaching, supervision and
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
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
More on ISBAR
Handover, Clinical Excellence Commission
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.
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
blog post has been republished with the permission of onthewards. Avant is not
responsible for the accuracy of any information contained in this
Share your view
We welcome your feedback on this article – email the Editor at: email@example.com