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In this episode, we speak with George Tewfik, an anesthesiologist, about the importance of recognizing and addressing knowledge gaps in anesthesia residents. George discusses how new residents may arrive with a sense of false confidence that can quickly become a liability, and how educators must earn the trust of their trainees to ensure patient safety. He shares strategies for promoting open communication and collaboration within the team, and emphasizes the importance of recognizing limitations and seeking help when needed. George also discusses how educational institutions and residency programs can better prepare trainees for independent practice by stressing the importance of patient safety and continuing education.

George Tewfik is an anesthesiologist.

He shares his story and discusses his KevinMD article, “Earning trust in anesthesia: How recognizing limitations can improve patient safety.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Get CME for this episode by clicking on the CME link in the show notes. Today on the show, we have George Tewfik. He’s an anesthesiologist. His KevinMD article is titled “Earning trust in anesthesia: How recognizing limitations can improve patient safety.” George, welcome to the show.

George Tewfik: Thank you so much for having me.

Kevin Pho: We’ll get to the article in a little bit, but first off, just briefly share your story and journey to where you are today.

George Tewfik: Sure. I graduated from residency in anesthesiology at Rutgers New Jersey Medical School in Newark in 2012. I went into private practice at Saint Barnabas in Livingston for about four years, then joined another small outpatient private practice group for about a year, and I’ve been back in academics for six years now at Rutgers in Newark.

During that time, I’ve been really interested in education for residents and medical students, as well as quality and patient safety. For the last three or four years, I’ve been in charge of quality assurance for the department of anesthesia at Rutgers in Newark, where we practice at University Hospital. In addition, I’ve been the head of the anesthesia simulation program and have been leading the clinical informatics initiatives for our department as well.

Kevin Pho: Now, through an anesthesia lens, tell me about that transition from private practice back into academics.

George Tewfik: It was definitely a struggle. In anesthesia, as a type A personality, you get very concerned about the little aspects of our job: how you tape a tube, what medications you give, and the timing of everything. When you’re in private practice, you’re in charge of everything yourself. You do it all yourself. You see the patient from pre-op all the way through post-op. No one relieves you; there are no lunch breaks or cases taken over by anyone else.

So transitioning back to academics, where you’re now supervising two, three, sometimes four operating rooms, takes a different degree of control and a different degree of trust in your clinician colleagues to be able to successfully navigate that transition. It’s definitely hard, and that’s kind of where the impetus for the article came from. It’s one of those things where people don’t understand that transition and how important it is for resident education. That transition can inhibit both your growth as an educator and the residents’ growth in their education as well.

Kevin Pho: Now, for those anesthesia residents who are considering job opportunities, you’ve been on both sides of the fence. What kind of questions should they ask themselves if they’re considering a private practice position versus an academic position?

George Tewfik: That’s a great question. It really does come down, a lot of times, to this: Do you want to develop your own skills and be in charge of the patient from pre-op to PACU yourself, 100 percent, and take on that responsibility? Or are you more interested in education, working in a collaborative team practice model where you work on ideas together, come up with anesthetic plans together, and really are collaborating on the patient care itself?

Kevin Pho: All right, let’s talk about your KevinMD article, titled “Earning trust in anesthesia: How recognizing limitations can improve patient safety.” How did this article come together?

George Tewfik: Like I said, I’ve been in education now for six years, back in an academic center. I love it. Working with residents and working with nurse anesthetists is fantastic. It just so happened that the impetus for the article was a couple of recent issues that I had as the head of quality assurance for my department. I get all of the adverse events that are reported, either through our staff, through the nursing staff, or through the hospital administration, and I go and review those. I had several in a row where I really realized that if the resident had just stopped to ask a simple question of their attending faculty member, something silly, a major problem could have been avoided.

So it was kind of brewing in my mind, and then I had one adverse event that personally happened to me with a resident. It’s not that I take it personally, but I was really surprised, because the first thing that I tell the residents when I work with them in July, when they come on, is, “I will never be upset with you for calling me for something. I’ll only be upset with you if you don’t call me. There is no question where I will ever say, ‘Hey, why did you ask that question?’ I really prefer it, even if it’s something super silly where you’re like, ‘Oh, a medical student should know this.’ I’ll be more upset if you don’t ask that and make a mistake than if you do ask that. It’s never a bother to ask a question.”

So many of these little tiny things blow up into something big because something small wasn’t asked, and that was really the impetus for writing the piece. It was trying to address both sides of it. As educators, we really should be creating that environment to make people OK with asking questions and not fearful. And the residents should really understand that asking questions is not a sign of weakness. In actuality, it really shows a sign of wisdom that they recognize that they have a limitation there.

Kevin Pho: So when you further discussed this with the medical team and the residents, did you get some reasons as to why those residents didn’t feel comfortable asking a question in a particular case, even when you gave all those assurances?

George Tewfik: A lot of times, it really does come down to the fact that they don’t realize that they don’t know, or that they really are fearful because they’re expected to know. By the time you get to your anesthesia residency, you were at the top of your class in high school and the top of your class in college, and you really excelled in medical school. You’re getting here, and a lot of times you think everyone’s kind of looking at you: the nursing staff’s looking at you, the surgeons, your attendings, your colleagues. When you’re a resident, they throw a medical student in with you to teach sometimes.

I think there’s a tremendous fear of feeling inadequate, or feeling almost like an imposter syndrome, if you’re standing there and you’re supposed to be doing something and you don’t know how to do it, or you have to take an extra second. In anesthesia, there are a lot of snap decisions, really quick things that have to happen, so people get fearful about taking a minute to ask a question. I think it really does hinder patient care.

Kevin Pho: Now, what are some of the techniques that you use to establish trust with your residents, especially since you’ll be working with new residents pretty much every few months, every year? How do you establish trust with your residents?

George Tewfik: That’s a great question. It’s really something that I think you’ve got to build very, very early on. Like I said, I have that conversation with the residents super early on, when I tell them, “Listen, reach out to me for anything. It’s never a bother,” even if I’ve got a meeting or a conference call or something administrative or a lecture or whatever. I tell them there is no question that I’ll ever be upset about.

I think you’ve got to build in that atmosphere of making them not feel inadequate or silly or anything for reaching out, and saying, “Hey, thanks so much for reaching out about that. I’m really glad that you asked that before you gave this medication,” or, “I’m really glad that you took the extra minute to really consider what this means for patient care before jumping to do something.” So it really is about building trust between the faculty member and the resident, and I think it’s something that’s got to start from your first interaction with them when they show up in July.

Kevin Pho: Now, among your other attendings, do they have that similar emphasis in terms of asking questions? Because I think one of the reasons why residents and fellows are sometimes hesitant to ask questions is that they don’t uniformly have a supervisor who is so open, who has that open-door policy. I’m sure they may have had a negative experience when they previously asked questions of a prior attending. So what’s it like among your other teaching attendings?

George Tewfik: That’s one of the things I struggle with as the head of quality for the department. I really try to stress to the other faculty that playing that blame game all the time, especially in M&M conferences and when we’re reviewing adverse events, is never really something that should be looked at as a disciplinary action or something that’s a negative for the resident themselves. What we’re really trying to do is create a culture in which people feel open to bringing errors out and are not feeling shamed for asking a question or for making a mistake. That’s not to excuse someone who’s being careless or reckless, obviously. But if you create a culture overall where people are willing to bring their errors or their concerns out to the public, I think that’s something that overall improves patient safety.

There are several times when I’ve had to tell other faculty members, “Listen, take it easy. We’re going to present a case that’s particularly troublesome or traumatic for the people who are involved. Don’t attack the person and make them feel like they are being shamed publicly in front of other people.” It’s really to create an educational atmosphere, and one in which we can bring out problems to try to address something together as a department.

Kevin Pho: Now, what happens when residents and fellows make mistakes and you have to give feedback on those mistakes? How do you approach that situation?

George Tewfik: It’s always tough, because people take it very personally. We have a lot of empathy, obviously, toward our patients, and especially when you have something particularly catastrophic, it could really impact the person themselves. So I’m really mindful, first and foremost, of the second victim effect when someone has something particularly adverse happen to one of their patients.

Before we even get into the error, I try to tell them, “Hey, how are you feeling? Do you need to talk? We have mental health resources that are available if someone has something that they really need to work through.” I try to address that first, before we get into the actual error itself, because I don’t want someone to take it so badly that it affects their other patient care. Once we’ve cleared that, I sit down, start with the facts, and have them lay out exactly what happened, step by step, and have them work through it. Then we kind of get into debriefing each one. Sometimes we’ve got to bring in a faculty member as well; sometimes we bring in their mentor or advisor and the chief residents. It just depends on each situation. But I try to shift from addressing their mental health and well-being first to then getting into the case itself.

Kevin Pho: Now, specific to new anesthesiology residents, what are some typical blind spots that you see? Any trends or patterns that they need to be aware of?

George Tewfik: The first thing is really understanding when it is time to call. Pretty much after the third or fourth week of an anesthesia residency, just by logistics alone, the anesthesia attending has to be able to leave the resident in the room by themselves. That’s nerve-wracking just as much for the faculty members as it is for the residents themselves once we leave the room. So at that point, the critical transition is understanding when it is important to call. The first time you see a patient go from a heart rate of 80 to 110, that’s a good enough reason to call and say, “Hey, what’s going on here?” Then you can work through a differential diagnosis of tachycardia or hypotension.

Over time, as an anesthesia resident, you’ll build confidence and be able to understand, “Hey, I’ve seen this before. I can work through the problem, understand what this physiologic derangement is, and then be able to successfully treat it.” But making that transition, and being able to understand what is something I can address on my own and what is something that I need another pair of eyes on, is the critical issue in success in anesthesia.

Kevin Pho: Yeah, I agree with you. So there’s that balance between fostering independence and knowing when to call for help. In general, how long does it take for a new anesthesiology resident to develop that balance between independence and knowing when to ask for help?

George Tewfik: Some people get it right away. You’ve always got a couple of residents who text about every single thing or call about every single thing, and like I said, that’s totally fine. And then there are some who hesitate a little bit. But generally speaking, within about a month or two, most of the time, the residents really do figure out what is something that is worth calling to my attending’s attention and what is something that I should, at this point in my career, be expected to understand.

It really has a lot to do with expectation setting on the part of the faculty, the chief residents, and the senior residents. Everyone really needs to work in concert together and say, “Hey, at this point, you should be able to handle this problem,” or, “At this point, this problem is too big. You’ve got to call someone senior to be able to address that.” So it really is a collective effort. It has to be on everyone’s part to be able to help someone, especially when they’re new, to try to figure that out.

Kevin Pho: We’re talking to George Tewfik. He’s an anesthesiologist whose KevinMD article is titled “Earning trust in anesthesia: How recognizing limitations can improve patient safety.” George, tell us some tips that you want to share with anesthesiology residents. Other than calling for help and having that open door, are there any other tips that you can share with them?

George Tewfik: The big thing, really, for an anesthesia resident is to understand that you really are part of a team. A lot of times, we get isolated. You look at your own case, and you’re in an operating room all day by yourself a lot of times, especially if it’s a long case, and it’s hard not to feel isolated. But anesthesia really is a team sport, and the earlier that you recognize that as a new resident, the better your progression as a student, as a trainee, and ultimately as a practicing anesthesiologist will be.

We really cannot function by ourselves in a vacuum. Even if you end up practicing in a small hospital one day, with a small group, anesthesia really is a team sport. You’re interacting on a daily basis with the surgeons, the nurses, the hospital administrators, and then all the different consulting services that help to contribute to patient care: the medical physicians, the cardiologists, and the pulmonologists.

In anesthesia, when you’re starting out, a lot of times it’s very easy to feel isolated. You don’t see your co-residents or the chief residents or all the faculty at a single time. It’s important not to feel isolated, and to recognize that you really are part of a big care team, and to understand that those interactions with the other care team members really can contribute very positively to our patient care, to patient safety, and to your mental well-being as a physician. It’s very easy to feel isolated like that, but once you understand that the continuum of patient care really is very big, and that you’re one critically important but one cog in that wheel, it really does help to bolster your confidence and your understanding of where you fit into the patient care team model.

Kevin Pho: And my final question, George: Tell us some of the take-home messages that you want to leave with the KevinMD audience.

George Tewfik: I really hope that people who read this article understand, from both sides, how difficult the transition can be at the beginning of someone’s residency. As a faculty member, I get palpitations every time it gets close to July, because you finally get into a groove with the residents. You know which ones you’ve got to keep a close eye on and which ones you can give a little bit more of a leash and more independence to, come April or May of an academic year. And then, as July comes, here comes a new batch. For us, with a three-year residency, a third of our residents and trainees are going to show up, and now it’s a whole reset. Now you’ve got to figure out all over again who is trustworthy and going to be able to call in an emergency, and who you’ve got to keep an extra close eye on.

But recognizing on both sides that the transition is difficult, I think, is really important. We’ve got to understand that these residents are showing up, especially for anesthesia, when their last anesthesia rotation, by the time July comes around, was probably a year and a half ago in medical school. They just did a medical internship or a surgical internship, in which they spent their whole year on the floors, doing scut work a lot of the time. So now we’re throwing them into this brand-new environment where they don’t know anything, and if our expectation setting is such that we think they’re going to be like one of the third-year residents who just graduated, that’s setting up both sides for failure.

So I think it’s about recognizing that the transition is difficult on both sides. And the residents have to understand, too, that as attending physicians, as faculty members, our responsibility is to that patient. They may physically be the one in the room, or fear that they’re the ones who are going to get yelled at if they make a mistake, but the responsibility really does come back to us. We’re trusting them with the patient care for the patients that we are taking care of in the operating room at any given time, and that trust really does need to work both ways for us. So I think that really understanding the dynamics that are at work while we work in this patient care team model will help both sides set up for success.

Kevin Pho: George, thank you so much for sharing your time and insight. Thanks again for being on the show.

George Tewfik: Thank you so much for having me.