When doctors give orders
Reporting about Martin Romualdez’s hospital admission has brought the roles of junior and senior doctors under public scrutiny.
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Reporting about Martin Romualdez’s hospital admission has brought the roles of junior and senior doctors under public scrutiny.
THE relationship between residents and consultants shapes both patient care and the training environment.
Photo courtesy of Mateo Hernandez Reyes/Unsplash
When I send a resident an instruction on my phone, I can put the phone down. The resident still has to return to the bedside, coordinate with the nurse, enter the order, and see what happens next. A resident is already a doctor, but one undergoing specialty training under more experienced physicians, whom we call consultants. The family may know my name while recognizing the resident as the doctor who keeps coming back. That doctor may be reassuring them while still needing reassurance about the plan. This is why supervision exists. The arrangement works only if the resident can call me again, including to say that my instruction needs another look.
Reporting about Martin Romualdez’s hospital admission has brought the roles of junior and senior doctors under public scrutiny. I have not reviewed the complete medical record and will not assign fault in that case. But it raises a question that belongs in every teaching hospital: what do we owe someone who is responsible for patients while still learning how to carry that responsibility? We ask residents to be honest about what they do not know. We cannot reasonably ask for that honesty and then make uncertainty a source of shame. A resident should have to earn increasing independence. They should not have to earn respectful treatment. That matters most when the resident is struggling, not only when they excel.
In nephrology, this becomes practical very quickly. Dialysis can remove excess fluid that is making a patient breathless, but fluid removal can also contribute to a fall in blood pressure. If I prescribe an amount to remove, the team needs to understand the goal, what should prompt reassessment, and when to call. A report that the patient is no longer tolerating treatment requires more than a reminder of what I ordered. I may have more experience; the resident and nurse may have more recent information. I need it to decide whether the prescription still fits the patient. I expect the resident to assess what has changed, but not to delay an urgent call until the presentation is perfect. Once the immediate problem is addressed, we can work through the reasoning together. Otherwise, I have helped complete a task without necessarily helping train a doctor.
Treating residents better does not mean expecting less of them. They must examine patients, check results, follow through, and tell the truth when something has gone wrong. They owe nurses and more junior colleagues the respect they expect from consultants. A trainee who repeatedly acts unsafely may need closer supervision or restrictions while the difficulty is addressed. That protects patients while giving the trainee a chance to improve. A dangerous action may need to be stopped in front of others. The fuller discussion can follow privately. What was missed? Why did it matter? What must change? A resident should leave the conversation knowing what to do differently, not merely knowing that I was displeased. I owe that effort especially to the trainee I find hardest to teach.
The difficulty is that I help evaluate the same residents I ask to question me. What feels to me like a discussion about a patient may feel to them like an examination. In a Filipino ward, I should not assume that “Opo, Doc” means a concern has been resolved. When I evaluate trainees, “receptive to feedback” must not become a polite way of saying “never disagree with me.” I need to hear the question before judging the attitude. The resident who makes my day easier is not necessarily the one exercising the soundest judgment. Families cannot be expected to recognize every problem in a treatment plan. A resident who respectfully interrupts me may be doing something the patient cannot do for themselves. The patient’s safety gives me a reason to listen even when I would rather finish the conversation.
That obligation extends to paperwork. If I ask a resident to prepare a medical summary, I owe them more than a deadline. A summary may bring together findings recorded by several clinicians; compiling those findings is not the same as claiming to have personally made them. Before signing, the resident must check that the summary accurately reflects the record and understand what their signature certifies. I must verify the clinical conclusions I ask them to convey. A request for clarification is part of doing the work properly. If the document is later questioned, the person who prepared it must explain their part. Those who supplied or approved its conclusions must explain theirs. Supporting a resident does not require declaring them blameless or concealing a mistake. If I made the decision, I should explain it myself rather than leave the resident to explain both of us.
As a hospital leader, I cannot leave this to whether a resident happens to have a considerate consultant. Accepting trainees means making room for the work of teaching, not simply filling a duty roster. There must be reachable supervision, dependable cover when the assigned doctor is unavailable, and somewhere to take a concern about the supervisor. Consultants need time and support to teach; residents need workloads and rest that allow them to think. A shortage of staff does not make an inexperienced doctor ready for independence. I also need to know what happens after a concern is raised. Was it examined fairly? Did anyone help? A hospital cannot judge its training environment solely by how few complaints reach management. I would want to know whether trainees trust that asking for help will lead to help.
The evaluation forms I complete ask how much supervision a trainee needed. It is a necessary question. We need to know who is ready to work more independently and who still needs help. But the question also points back at me. Did I explain enough? Was I available when the plan stopped working? Did my response make the next call easier or harder? A resident may be learning how to treat a patient and how to treat a younger colleague in the same exchange. Years from now, someone else may be on the receiving end of what I taught. Before I write that a trainee needed more supervision, I ought to be able to say how much I actually gave.
