Patients refusing resident procedures

[anes]

I've had this issue a couple of times while on OB. The lady comes in 10/10 pain gives full h/p, then states "I would like the attending to perform the epidural". You explain that the attending is busy and may not be available for some time. 20 minutes later you get a call from the nurse saying "Doc, the patient would like an epidural NOW, and she says its's ok for you to do it".

How do you respond? Do you go and do the epidural?

It doesn't bother my ego (much), however I don't feel comfortable doing any procedure on that patient now. If anything goes wrong (wet tap, spinal headache, paresthesia...) they'll say "thats why i wanted an attending. I'm always worried about doing a procedure on a patient who had no faith in me, and now using me as a last resort.

Can you refuse and say "well I don't feel comfortable doing it now, and we should wait for the attending"?

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[Precedex]

It's really about whether the attending is comfortable with you doing it alone since that person is attesting that they were supervising you and is responsible for anything that happens. In my experience some attendings want to be present for all epidurals, others could care less- I'm sure this is institutional and situation dependent.

 

[rsgillmd]

As Precedex said, we are assuming you are comfortable performing the procedure on your own and your attending is comfortable with you performing it on your own.

I've been in this situation many times when I was a resident. The vast majority of the time it is just fear/anxiety talking when they request an attending only. As part of my pre-anesthesia interview in these patients, I'll ask if they have had a problem in the past or if they have any specific concerns I can address before I go get the attending. If the attending may not be immediately available I'll let them know that.

If you are comfortable performing the procedure on your own, and would have been doing so anyway if the patient had not made a request, then by all means go ahead and do it when the patient relents. Take care of the patient. The vast majority of the time when they get pain relief they'll end up being apologetic and thankful.

I think we had a thread similar to this just a week or two ago.

 

[deleted126335]

Depends on the attending. Some cave. Some will politely explain to the patient that this is a teaching institution and if you don't want residents, please take your business elsewhere. Some will simply be "unavailable" for an elective epidural. Some will tell you to handle it.

Your role as the resident is simple. Communicate with your attending and defer to his judgement. Your last line about subsequently explaining to the patient,"well I'm not comfortable..." is nice to fantasize about saying, but really unwise thing to actually say.

 

[error404]

I've had this issue a couple of times while on OB. The lady comes in 10/10 pain gives full h/p, then states "I would like the attending to perform the epidural". You explain that the attending is busy and may not be available for some time. 20 minutes later you get a call from the nurse saying "Doc, the patient would like an epidural NOW, and she says its's ok for you to do it".

How do you respond? Do you go and do the epidural?

It doesn't bother my ego (much), however I don't feel comfortable doing any procedure on that patient now. If anything goes wrong (wet tap, spinal headache, paresthesia...) they'll say "thats why i wanted an attending. I'm always worried about doing a procedure on a patient who had no faith in me, and now using me as a last resort.

Can you refuse and say "well I don't feel comfortable doing it now, and we should wait for the attending"?

I know my attendings wouldn't be comfortable with me refusing the procedure...

My first step is usually to ask the patient WHY they'd prefer the attending. About 80% of the time, they have no insight into the system-- they think I'm a RN or med student, or their birthing class simply told them to ask. I'm comfortable telling them that the procedure is USUALLY done by residents, who have more recent hands on experience than the attendings. And I tell them my numbers. I've been in medical training for 8 years, and was recently asked to do the epidural for one of my anesthesia colleagues. Between that talk and the fact that the attending usually isn't immediately available, I'd say nearly all patients are then convinced they'd LOVE me to do it.

But yeah, I find its a huge ego hit whenever a patient refuses a procedure from me. Do I look to young? Too female? Why don't they love me?

 

[Oggg]

Seriously, I would not let anyone but a senior star resident put an epidural in a family member. I wouldn't let CA-1-me come near my family. Some attendings are idiots, but at least they have some experience under their belt.

 

[jwk]

Seriously, I would not let anyone but a senior star resident put an epidural in a family member. I wouldn't let CA-1-me come near my family. Some attendings are idiots, but at least they have some experience under their belt.

Usually - but not always. We had one recently with 10+ years of experience when he came to us - he couldn't buy an epidural to save his life.

 

[Oggg]

Our OB director in residency was well published but a complete nincompoop

 

[Sonny Crocket]

In my residency we had so many procedures that if this ever came up I would say no problem, call my attending, and they were always happy to do it. I did not feel bad at all.

 

[Gern Blansten]

In my residency we had so many procedures that if this ever came up I would say no problem, call my attending, and they were always happy to do it. I did not feel bad at all.

That describes my place as well. As an attending, it is nice to get requests every once in a while. The majority come from employees. Sometimes they request a specific resident. Sometimes they request a specific attending. Sometimes they just a have a list of a couple of people that they will refuse to have do it. I try my best to never be on that list for anyone.