How do you handle incompetent residents?

[simvee]

I work in a teaching hospital with several residency programs. Lately we've become a "closed unit", using intensivists, but we "borrowed" the intensivists from the pool of already overworked trauma surgeons and pulmonologists (it's not like they brought new MDs on board), so sometimes there's even "intensivist residents" now.

Typically the residents have to be 2nd year to give orders in the unit, but sometimes they're 1st year, even for intensivist coverage of the entire unit!

I'm still new, but I know more about critical care than some of these physicians. That doesn't bother me too much (though I question giving them intensivist coverage!) but I hate when they give me pat answers to shut me up. I'll alert them to a problem and they won't know how to deal with it, but they are afraid to wake up or bother the actual physicians on the case, so they say it's fine (it's always fine). If I suggest a solution, it's always "that's fine, you can do that if you want" like it doesn't matter one way or the other. If I know for sure that the intensivist or surgeon is going to come in the morning and herniate their brain over this unresolved problem, I tell them that. But I'm new, so I don't always know.

Or they just don't know the basics of critical care. One memorable night I asked what our plan was with a crashing patient since the levophed was not working - could I start neo or are we calling the family?? "What's neo?" is the response I get. You know, neo-synephrine, phenylephrine....a pressor! He starts talking about whether dopamine would be appropriate...doesn't that increase urine output? I don't really think so, but that's beside the point. Give me something to work with before we have to call a code.

I find I depend a LOT on the more experienced nurses. I haven't yet had to go over the head of an "it's fine, it's fine" resident, and I'm kind of afraid to. What other options do you have?

Any advice?

[grandmawrinkle]

I work in a teaching hospital as well. The residents run the unit in it's entirety. You are lucky if you have had attending-level intensivist coverage 24 hours a day in this setting. Our attendings are rarely on the unit, if at all, and if they are there, they are there for about an hour rounding, teaching, and helping the residents formulate the treatment plan. Our attendings are called in the event of an emergency, and often then, they don't even come in, they just help manage/consult over the phone. This is not an uncommon scenario -- I think yours is probably more unusual.

Residents don't always know the fine points of critical care management, especially in the summer with new interns, etc. If they don't know what to do and they do nothing, that's their call. If the patient is not getting expert level care....that is the name of the game with interns and residents. There is a learning curve, and, to be fair, attending doctors even make mistakes sometimes. You can only go so far with making suggestions. If you have a crumping patient or things are otherwise unsafe with what they are prescribing/doing, they should be calling their attending for assistance. If they don't do that, YOU should be calling the attending. If this happens, usually I will just say...."did you call Dr. X...because if you don't, I'm going to have to, and that's not going to go over particularly well." That usually gets their a** on the phone in about 10 seconds.

You need to keep in mind that the chain of command mentality is very much alive in full force in the pecking order of the medical community. Those interns and residents are sometimes scared to prescribe what they think is best because they don't know what their attending wants in that situation -- and they would rather not get yelled at for doing something that their attending doesn't approve of. If it can wait until they can consult with them, they often will postpone treatment.

[tri-rn]

I work days, so as far as calling and waking someone up...I haven't had to do it. I will usually just grab the fellow if I have a bad feeling, and run whatever the situation is by them.

On a tangent, the thing I REALLY hate to hear is "what do you usually do in this situation?" I think that's code for "I'm clueless, I got nothin'".

[meandragonbrett]

Intern-->Resident-->Chief Resident-->Fellow-->Attending

[simvee]

You guys are right, follow the chain of command. It's kind of annoying to do this for little issues, though. Oh well.

Tri-RN, like I said, I'd rather them say they have no clue and ask me what to do than to make up a pat answer that I know is wrong.

[tri-rn]

Tri-RN, like I said, I'd rather them say they have no clue and ask me what to do than to make up a pat answer that I know is wrong.

Agreed....wholeheartedly!