Hi everyone,
Strictly speaking, resident responsibility is more aspiration than reality. Attendings bear ultimate responsibility for patient care: looking over residents’ shoulders, attesting notes, and tweaking plans.
It wasn’t always like this. As a resident, I once told an attending to stop talking during a code to show I was in charge. At night, we rarely wakened attendings except to discuss ICU admissions. Residents were praised for independence, not for seeking help. We may have been more self-reliant back then, but safety suffered, and we learned less from our attendings than we could have.
Effective attendings supervise residents while nurturing responsibility. As attendings, we must review progress notes for accuracy, check in regularly to “run the list,” explore what residents understand, and correct errors before they cause harm. And yet, we don’t want helicopter attendings who take over rounds, hand down decisions, and transform residents from active to passive learners. That approach would stunt growth. Rather, attendings need to listen closely as trainees present patients, reason through problems, and articulate plans. The attending’s job is to probe (“why is her sugar so high”?), push (why are you worried about PE”?), and fill gaps (“should we cover atypicals”?).
To build communication skills, we need to let residents lead discussions with patients and families, supplementing if needed. As we leave the patient’s room, we can provide real time feedback, for example suggesting simpler language while highlighting the resident’s gentle voice and encouraging words. That’s how we build skills, confidence, and independence.
Careful attendings know what’s happening under their watch, often by working behind the scenes: scanning vital signs, labs, and med lists before rounds and reading progress notes thoroughly before attesting them. I prefer to leave residents alone in the workroom so they can tackle problems before turning to me, though I’m always available. I also let them respond first when called to the bedside, knowing I can join them in a heartbeat. During codes, I stand just behind the resident, whispering suggestions while making mental notes for a post-code debrief. I’m poised to take over but rarely have to.
We’ve designed our program to promote progressive responsibility. We give early interns near-continuous oversight, but as their skills evolve, we step back. By PGY2 year, residents are ready to lead their own teams, and by PGY3 year, they are ready for capstone rotations—Whitman, Hospital Medicine, VA MICU, and YNHH MICU MARS—to show they’re ready to be attendings themselves.
To grow, residents need to work “as if” they were on their own, reasoning through diagnostic challenges, asserting their ideas on rounds, and stepping forward during emergencies. To foster resident growth, attendings need to speak judiciously and strategically during rounds, serve as role models, and provide feedback which is both encouraging and challenging. That’s how we ensure residents are ready for independent responsibility by the time training ends.
Enjoy your Sunday, everyone. The soles of my bike shoes broke, so this afternoon I’ll be climbing, not biking, up East Rock.
Mark
P.S. What I’m reading and listening to:
- Keeping the Faith: God, Democracy, and the Trial That Riveted a Nation by Brenda Wineapple
- Remember More, Forget Less on Hidden Brain with Shankar Vedantam
- The Climate Peril We Overlook by Nicholas Kristof
- Margaret McGovern: Building an Integrated Health System on Health & Veritas with Howie Forman and Harlan Krumholz
- Why Thousands of Haitians Have Settled in Springfield, Ohio by Miriam Jordan