The reality is that 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 patient.
– Abhi Pal
In starting my internship I came to the sudden realisation that now I am a doctor. Now I have responsibilities and I have to know stuff. Like really know stuff… Like to do my job properly. I used to think that on graduating medical school you receive a certificate that symbolises that you now have the required knowledge to be a doctor. You’re ready and you have learnt all there is to know. As the Wizard of Oz once said ‘universities…where men go to become great thinkers. And when they come out, they think deep thoughts and with no more brains than you have. But they have one thing you haven’t got: a diploma’. But unlike the scarecrow my certificate did not quite instil in me an unwavering confidence about how I would manage in my first year of practice.
One of the most daunting things about graduating from medical school and starting internship was the prospect of not knowing what to do and having to ask someone for help. I felt like the act of asking for help by default was an admission to being inadequate, unprepared and some kind of impostor who should never have graduated. I am sure that 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… Those first few weeks of internship 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.
Previous studies have found that barriers to escalating patient care include perceived issues accessing more senior staff, lack of judgment about when to seek help (aka situational unawareness) and concern about negative responses from senior staff . I was most worried about negative responses and being dismissed or reprimanded for not managing a task independently.
I started my internship on relief term. These are notoriously difficult, and without asking for a lot of help, completely insurmountable. I cannot even count the number of times I had to phone a friend for help with a cannula. I am better now but definitely not 100%. Thankfully that’s okay because I have later seen peers more senior than me ask for help with cannulas too. Sometimes they are materially difficult.
There have also been plenty of situations where I have felt out of my depth in my ability to manage a patient. 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 to call for help. I needed someone else to corroborate my examination findings and determine how extensively he needed to be investigated. Continued assessment and investigations determined he had a hypoactive delirium and I was satisfied that getting advice early was necessary.
There are also situations where, in hindsight, I probably could have managed on my own. For example, 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 outweigh the concerns I might have about asking someone more senior to confirm my assessment. I often feel that 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 different situations and clinical structures. 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 that these questions do not justify a specific phone call . 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.
Really, seeking help should be easy. Junior doctors should feel supported and confident that they are practicing safely. In my experiences so far I have felt this is the case, but I think I am fortunate that there is a strong emphasis on supporting junior staff at my hospital. It is something that needs to be ingrained in the culture of the staff. One of my best experiences of this was during my obstetrics term where the other residents and myself agreed from early in the term to help each other and provide assistance whenever we were able, so we all worked towards 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 have had when asking for help and it is difficult to gauge how often it is 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 that you’ll need help during internship so you can prepare for it.
A useful starting point is to practice and be familiar with ISBAR (see links below). It frames the situation, the patient and relevant pertinent information that is easily understood by the receiver. And like all clinical skills ISBAR takes practice. At the beginning of internship I needed to work harder to formulate a concise summary or handover of a patient.
In order to improve some strategies I found helpful are:
Although it is easy to feel inadequate due to needing help, ultimately you are keeping patients safe by seeking senior help when your unsure or not confident. It is a sad reality that people may belittle others for needing help but finishing medical school gives you the knowledge to begin learning how to do your job rather than making you an all-knowing, all-skilled super intern. Internship is part of your training and should be filled with teaching, supervision and learning.
One of the best things you can do now or at the beginning of internship is to practice handing over or talking about clinical situations in the ISBAR format with feedback from peers and supervisors. 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 is important to remember your knowledge and skills will exponentially improve in your early training, most often from asking for help, and this all contributes to shaping your clinical identity and independence.