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Working without supervision

In a tough economic climate, healthcare and medical expertise have to stretch much further. Working with limited supervision increases the risk for junior doctors and for patients, says Sarah Whitehouse

In an ideal world, you should have a clearly established mentor on hand to assist with any clinical queries that arise throughout your intern journey. The HPCSA recommends that all interns should be supervised by a registered medical practitioner with at least three years of post-internship clinical experience in that specific domain of training.1 Your hospital should have an intern curator who can help with training. But, as Dr Lynelle Govender highlights on page 6, this is not always the case.

Not only are some interns working unsupervised, they are working unsupervised in hospitals that are severely understaffed, further increasing the risk to patient safety. If you find yourself faced with a clinical situation where you feel out of your depth, remembering that you must work within the limits of your competency is the key to staying safe. Recognise your own limitations and do not practise beyond your skills and expertise, unless in an emergency. The HPCSA states that all doctors must “Acknowledge the limits of their professional knowledge and competence. They should not profess to know everything”.2

All doctors must acknowledge the limits of their professional knowledge and competence. They should not profess to know everything

You must feel thoroughly competent when diagnosing and giving or arranging treatment. All doctors have a duty to ensure that they have the necessary understanding of a procedure to take consent. If you don’t, ensure that consent is taken by someone who does.

Senior colleagues who delegate care or treatment to you must be satisfied that you have the appropriate experience, qualifications, knowledge and skills to provide the care required.

In some instances, however, particularly in rural areas, the junior doctor may be the only doctor on shift. There really might be no-one else to ask. The Sowetan Live recently reported that some intern doctors working at Cecilia Makiwane Hospital’s surgery unit in Mdantsane fear for patient safety because they are working without adequate supervision.

The newspaper reported that only emergency care could be provided because there were simply not enough senior doctors to perform operations.3 The response to this situation mirrors the HPCSA’s advice, that in an emergency, doctors should “provide healthcare within the limits of their practice, experience and competency. If unable to do so, refer the patient to a colleague or an institution where the required care can be provided”.

If you do find yourself overstretched, you should still take a thorough medical history and an examination if necessary – and document both. Record-keeping standards can easily slip if a ward-round overruns, but it is important to stop and make notes before rushing to see the next patient. Be aware too of “by the way” comments, where symptoms might be mentioned in passing. Make sure you record these conversations.

Stretched healthcare resources can often result in doctors feeling pressurised into working in unfamiliar areas. Dr Graham Howarth, MPS Head of Medical Services (Africa) states: “We have received a number of calls from hospital doctors who feel uncomfortable at being asked to provide cover for an area they do not normally specialise in because of staff shortages. If you find that you are so overstretched that the situation is in danger of putting patient safety at risk, or your health begins to suffer, you should raise your concerns within the appropriate channels, for example a senior colleague or your employer.”

The HPCSA states that you should “Always regard concern for the interests or wellbeing of your patient as your primary professional responsibility”. Your supervisor, Head of Department and CEO of the hospital must be promptly informed of your concerns in writing.

Dr Howarth adds: “From a medicolegal perspective, you should ensure that the authorities are made aware of the problems facing patient safety. It is prudent to keep a good record of all correspondence which details your concerns.”

Are you competent to take consent?

Dr U is in his first week as an intern at a large rural hospital in the Eastern Cape. A nurse asks him to consent a patient going to theatre; she cannot locate the consent form in the patient’s notes. She says that the consultant will be cross if the patient turns up to theatre without the appropriate documentation, especially as the patient’s operation has already been cancelled once, and it would be terrible if it happened again. Dr U appears unsure, so the nurse adds that Dr U would only have to take consent for a tonsillectomy, which “isn’t difficult”.

Dr U is in a dilemma that many interns will be familiar with. The nurse is asking Dr U to work outside his competence, as he has not taken consent from a patient for a tonsillectomy before. So how should Dr U handle this situation?

  • MPS’s advice is that Dr U should seek advice from a senior colleague before obtaining consent (if possible) so that the operation can go ahead as planned.
  • Trust, confidence and good communication are fundamental to a successful doctor–patient partnership and providing healthcare involves decisions which should be made with your patient.
  • Failure to obtain consent properly can lead to problems including legal or disciplinary action against you.

A personal account

Lack of supervision as an intern is a reality, says Dr Helet Potgieter

"It certainly was for me as an intern in Kwa-Zulu Natal in the mid-1990s, and probably still is to this day. My own experience of lack of supervision was a horrendous ordeal, and will stay with me all my life.

"It happened, as emergencies often do, at two in the morning during my surgical rotation. As the surgical intern I was on duty for the Intensive Care Unit. I was called from the ICU to attend to a premature baby who had surgery for bowel atresia during the course of the day.

"The baby was now showing signs of distress with difficulty breathing and low oxygen saturation. I was clearly out of my depth, and as I received the call from the nurse at the intensive care unit I immediately called the senior medical officer for assistance. I rushed to the unit, expecting a call back from the medical officer at any time. As I walked into the unit I saw that the baby was indeed in serious trouble. He was tachypnoec, the blood pressure was very low and the oxygen saturation unrecordable.

"I frantically paged (the days before cell phones) the medical officer on duty, but to no avail. I remember trying to resuscitate the neonate to the best of my abilities, but even now as an experienced anaesthetist, it is a difficult task, let alone when you are an intern.

"I am sorry to say that the baby didn’t make it. The incredible sense of being out of your depth, and the intense frustration of just not knowing if you are doing the right thing, has stayed with me for a long time.

"Now, as an experienced anaesthetist, I appreciate that the baby was probably beyond saving by the time I arrived on the scene, and I can sleep easy in knowing I did what I could. Although on paper this is the type of situation that should never happen, there is no doubt that it does happen, and probably much more regularly than it should. Elective situation is one thing, but it is the emergencies that force your hand and young doctors have to manage cases they are just not yet trained for.

The incredible sense of being out of your depth, and the intense frustration of just not knowing if you are doing the right thing, has stayed with me for a long time

"This incident, albeit traumatic, shaped my medical career from then on. I decided that I did not want to be in that situation again. It influenced me greatly to hone my skills in resuscitation, and ultimately pursue a career in anaesthesia, where skills in managing airway and resuscitation are paramount."

Dr Helet Potgieter is a specialist anaesthetist working in private practice in Cape Town.

  1. HPCSA, Handbook on Internship Training (2007)
  2. HPCSA, General Ethical Guidelines for the Health Care Professions, Booklet 1 (2008)
  3. Sowetan Live, Trainee doctors fear they may kill patients (10 January 2013)