The next time you’re walking through the hospital, look for “The Card.”
Within the next two months, surgical residents at the four largest Harvard teaching hospitals will have received a card that has been carefully crafted to improve communication between attendings and house staff. The card is the result of several years of work by the Chiefs of Surgery at Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Children’s Hospital Boston, and Massachusetts General Hospital, who were brought together by CRICO/RMF to work on improving safety for surgery patients.
This surgical safety collaborative was guided by problems the chiefs had identified clinically. These impressions were reinforced by data from the malpractice experience where studies of claims have found communication failures in 70 percent of cases. Informal discussions between these surgeons—who already knew each other but seldom worked directly together—led to a focus on developing ways to prevent those failures.
Practical experience said that attendings were not always aware of changes in the status of their patients, at times changes that might require their expert guidance. There were probably a number of factors at play here. Residents in the teaching hospitals are at the frontline of patient care and play an essential role in helping sick patients get better but, sometimes, inexperience can put them in a situation where they do not know what they do not know. And sometimes, they don’t want to bother the attending (especially at night) for advice.
Residents, better than anyone else, know how hard their attendings work and how much they give to their patients—they want to let them sleep. Occasionally, the residents might be afraid to call for fear of being berated or of admitting that they do not know what to do. There is also bravado—a sense that the best residents do not need the attending’s input or advice—that can get in the way. All of these issues were carefully considered in building the card.
The surgical chiefs were aided in this process by a working group of attendings assembled to debate, discuss, and formulate a plan. In the end, emerged “The Card”, a token or a symbol of an effort to open lines of communication for the patient’s benefit. The residents and attendings will benefit as well via opportunities to teach and to learn that might have otherwise been missed.
In each of the hospitals, The Card has provided a chance to send a clear message to the house staff: the attendings want to know what is going on with their patients and they want you to call. In addition, it has been a chance for the chiefs to enforce that this and other efforts to improve patient care are important. As the card has been introduced and distributed to surgical staff, the most important message is not found in the words it contains. The primary message is, if you have to check The Card, you should call the attending.
So the next time you see a surgical resident, take the opportunity to ask him or her about The Card. If you are a resident, consider it your consent to call the attending. We will all sleep better—patients, residents, and attendings.
The Card
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