when do you ask the attending?

[kat82]

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this may be a stupid question (i am an MS4 doing an EM rotation) but when can residents order tests and order for meds without first discussing with the attending? ive noticed that at my institution, the residents usually start the patients workup (labs, imaging) before presenting to the attending, and order fluids, abx, pain meds, etc.

when are you autonomous, and when do you wait and see what the attending wants to do?

thanks!

 

[NinerNiner999]

Residents are licensed physicians by definition, and should be confident enough to order their own tests and direct their OWN workup. That being said, it would be wise for any resident to ask for attending guidance about ANYTHING they do not feel comfortable with or are unsure about. Every attending has their own practice style, and the goal of your training is to be exposed to these variants and develop your own. As an intern, these questions should be asked somewhat frequently and too few questions may raise a red flag.

 

[GeneralVeers]

Agree with the above. Our PGY-2 and 3 residents do all of their own workups, then discuss it with the attending. If there is time, I may discuss the patient before everything is back.

Our interns usually go over the case with the PGY-3 before ordering anything. Hopefully once they learn a little bit more they'll be able to handle more autonom y.

 

[EM_Rebuilder]

I think the norm has already been stated. My very first shift in the ED, I would not give a Lortab without asking the attending about it first. After a month, I would do basic stuff, but even still, I would go over my complete workup before turning everything in (I do not want to spend thousands of dollars, wrongly, with the flip of my pen...or worse do something to jeopardize a patient). The key is to be proactive, have reasons for everything you are ordering, and (they say) eventually you are just comfortable doing it. Certainly the 'upper level' EM residents where I am at get all the balls rolling usually before d/w the attending. They usually get stuff back then d/w several of the patient at once before they actually D/C them. Usually the attending already saw the patients and (hopefully) just concur with what has been done.

They say we all figure it out eventually...

And no matter how senior we become... if we are not comfortable or not sure about anything, ask or look up the question before you do something you later realize you shouldn't have.

 

[Jeff698]

Remember that interns are not fully licensed physicians and are practicing under the license of thier program director and facility. They are not independent practitioners.

Further, by contract, upper levels are also not independent practitioners.

At our place, autonomy is progressive. First month interns generally need to ask permission to go to the bathroom. By the end intern year, they order initial labs and begin treatment before checking out (assuming they're confident in what they're doing).

Upper levels check out with faculty while labs/imaging are pending or when they're ready to make a dispo. They typically do it with multiple patients at a time.

I suspect most places are like this. I'm pretty sure the RRC expects to see progressive responsibility and autonomy.

Take care,
Jeff

 

[kbrown]

i present to the attending after my workup, or if i have a question about which direction to take, then i also speak with the staff. PGY-2

 

[EctopicFetus]

Here it depends on your confidence level with your workup.

Early in my intern yr I didnt know if giving morphine was ok. SO I asked the attending. After some time I do the workups im comfortable with. Now there are a decent number of patients where I will tell the attending, look here is the story here is the plan and here is their dispo.

Of course there are still times where the attending will want other tests. Personally, I think I under-order tests. I can usually justify any test I order but sometimes my differential is just not quite broad enough so I might have to "add-on" a test.

 

[docB]

This is a good question. I wan't to be asked about all invasive tests. I don't want my residents doing LPs or ordering angiograms without talking to me first. Radiology is in between. I wan't to hear about belly and chest scans. Plain xrays and head CTs are less of an issue. Labs I give them some freedom. If a liver panel gets ordered when it didn't need to be it's not going to harm the patient physically although they will get a bill they didn't need. Meds are a comfort level thing. Tylenol, morphine, zofran - go for it. Dopamine - talk to me.

 

[Sessamoid]

This is a good question. I wan't to be asked about all invasive tests. I don't want my residents doing LPs or ordering angiograms without talking to me first. Radiology is in between. I wan't to hear about belly and chest scans. Plain xrays and head CTs are less of an issue. Labs I give them some freedom. If a liver panel gets ordered when it didn't need to be it's not going to harm the patient physically although they will get a bill they didn't need. Meds are a comfort level thing. Tylenol, morphine, zofran - go for it. Dopamine - talk to me.

docB is inventing new contractions. 🙂

I think the short answer of when you ask your attending is "when your attending wants you to". They'll decide how much autonomy you're ready for, because that's part of their job. I haven't supervised residents for years, and not EM residents since my senior resident year. With off-service residents I wanted to be asked about everything immediately after the H&P. My comfort with my junior residents depended a lot on which particular junior we were talking about.

 

[docB]

docB is inventing new contractions. 🙂

docB can't type.🙁

 

[The White Coat Investor]

My pet peeve is residents getting consults without staffing the case with me first. A lot of times they don't need a consult from another service, they need a consult from their own attending.