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Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September

CLINICAL CARE AND THE CHAIN OF COMAND

Constance K. Haan, MD, MS Frank Genuardi, MD, MPH

Whether a medical student, resident, nurse or physician extender, or attending or practicing clinician, we have all been faced with the questions of “Do I call?”…and “When should I call?” Optimal team functioning requires the team leader to set expectations and for team members to know their roles and responsibilities and to feel comfortable communicating observations and ideas without fear of intimidation or reprisal. Caregivers should seek out and become aware of the supervision policy pertinent to their specialty service and share this information with trainees and non-MD team members as appropriate. Trainees should talk to the senior/chief resident and attending—creating a plan by discussing an algorithm of “if/then” guidelines and parameters for action, inquiry and reporting. This kind of communication of expectations and parameters appropriate for initiating a call is also useful for communication between MDs (residents and nonresidents) and nursing staff—especially at the beginning of a shift, or in facilitation of complete information at hand-offs. Timely communication with good information builds trust! The first key in communicating is being ready with essential information for diagnosis and/or assessment of status changes. The second key is orderly presentation of information in a manner that demonstrates logical, orderly thought processes. For the resident, orderly presentation of a thoughtful plan, while being ready with rationale and pro/con analysis for management options, demonstrates further good judgment and safe, independent thought processes. Identifying critical junctures for communicating with one’s supervisor is also critical to building trust. Examples of such critical junctures include: 1) When the plan or algorithm made has been exhausted, without satisfactory patient response (i.e., the plan is not enough), 2) when the patient’s condition doesn’t respond in a manner expected by the current understanding of that patient’s pathophysiology, and 3) When unanticipated changes occur— communicating for information only, or for further plan development. Faculty, clinicians, and consultants should make frequent use of briefing and debriefing for teaching opportunities on what went well and what should be done differently in the future—from both clinical and communication perspectives. Part of resident and student education should involve a review and discussion of situations in which a call was made inappropriately either too late in the course of events, or at a juncture where a consultation was not really necessary. These reviews should be conducted in a collegial, educational manner rather than a negative or punitive one. The bottom line in reporting information up the chain of command is to build and maintain trust with the supervising physician by the timely communication of information in a clear, concise, and accurate manner.