All physicians know the doctrine: First, do no harm. But perhaps for residents, a second, equally important motto should be: Fear no questions.

To explore the art of asking clinical questions, MDLinx interviewed two physicians who completed residency in 2020 and one residency-program administrator. While learning to apply clinical knowledge can be stressful, each of these interviewees said that residency programs encourage questions. Moreover, asking good questions is a skill that leads to better outcomes for residents and patients.

Addressing doubts

Doubting your abilities and decisions is a normal part of residency—and beyond. 

“It’s certainly nerve-wracking coming out of training and feeling like you’re on your own,” said Robin Friedman, MD. 

She’s a colorectal surgeon at Valley Medical Group in Ridgewood, NJ. Friedman completed a fellowship at Beaumont Hospital in Royal Oak, Michigan, in 2020, following her general surgery residency from 2014 to 2020 at Cooper University Hospital in Camden, NJ. 

It’s certainly nerve-wracking coming out of training and feeling like you’re on your own.

Throughout her training, Friedman found support when she needed it. The hard-nosed depictions of attendings in popular TV dramas thankfully are not a reflection of reality, she said.

“I was blessed with having training programs that weren’t malignant,” Friedman recalled. “They were really welcoming. They wanted you to really grow. They wanted you to inquire.”

According to Perry Lin, MD, assistant program director of Mount Carmel Health System’s internal medicine training program, residency programs should be “psychologically safe,” with the goal of “creating a nurturing atmosphere where learners feel comfortable being candid about their gaps and where it is OK to make mistakes.” 

Psychological safety and honesty go hand in hand, according to Lin. “Although patient safety is paramount, when a learner feels unsafe, they are more likely to hide their deficits. This creates a globally unsafe environment.” 

He added: “A psychologically safe environment allows our learners to be honest and seek help when they need it without feeling judged. This also builds into feedback. We ensure that we, ourselves, are open and honest with our learners, utilizing concepts like radical candor. This is important to ensure that your learner knows you want to see them succeed.”

Building confidence

According to Jayram Pai, MD, the feedback Lin described is essential. 

“Confidence issues can be addressed by debriefing cases with co-workers or supervisors to discuss management and see how a case could be approached differently,” said Pai, who did his emergency medicine residency at Mount Sinai Hospital in New York City from 2016 to 2020.

Pai added that residents should lean into graduated responsibility to ease the transition from having medical knowledge to applying medical knowledge.

“A new intern might be questioned more extensively on their thought process and approach to a diagnostic workup,” Pai said. “The same case might be a much more direct discussion with a senior resident with points on how to fine-tune their approach, given that they have years of experience under their belt at that point in their training.”

Of course, there’s no substitute for “learning, studying, and committing yourself to focusing on working on your weaknesses,” Pai said. This is a not unexpected reminder, coming from an assistant professor of emergency medicine at the Warren Alpert Medical School of Brown University.

Surrounded by support

Both Friedman and Pai said that confidence arises gradually from knowing the extent of your ignorance and striving to eliminate it. Friedman remembers what it felt like the first time a nurse called and asked if a patient could take acetaminophen. 

“I remember thinking, ‘We don’t have liver function tests. How do I know it’s safe?’,” Friedman said with a laugh. “Over a matter of weeks to months, you learn so much from your co-residents, how they respond to those situations, just by asking them. I think early on, your biggest teachers are your co-residents because you’re really not ashamed to ask anything like that of them.”

A senior resident has years of experience under their belt and can often answer many questions, and are often felt to be more easily approachable since they are viewed more as a co-worker or friend rather than instructor

More standard resources are also there to be consulted. 

“First and foremost, your attending—that is what your supervising faculty are there for, to guide you through your education!,” Pai pointed out. “That being said, a senior resident has years of experience under their belt and can often answer many questions, and are often felt to be more easily approachable since they are viewed more as a co-worker or friend rather than instructor.”

Every now and then, one of your questions may even surprise an attending.

“As a second-year resident,” Pai said, “I had asked one of my attendings about using a specific medication for a coding patient, and I was told it was a good thought that hadn't crossed his mind.”

This made quite an impression on Pai. 

“I hold that attending in extremely high regard,” he said, “and the realization that I contributed an idea that he found helpful came as a bit of a shock to me. Now, as an attending myself, that experience serves as a reminder that anyone on the team can have something meaningful to contribute.”

Don’t fake it until you make it

But don’t just contribute anything that comes to mind. Friedman also found herself on the teaching end of the educational equation in residency. She had a clear admonishment for her junior residents: If you don’t know the answer, do not guess. Ever.

“One of the first things I’d tell junior residents when I was a senior resident was that one of the best answers you can give me is ‘I don’t know,’ because then I know you’re never telling me false information,” Friedman said. “‘I don’t know’ is the safest answer for everyone.” 

Pai also left little ambiguity as to his tolerance for guessing.

“It is always better to ask,” Pai said. “There's been a conscientious shift in medical culture over the years. It's often considered the hallmark of a mature resident to recognize when they are out of their depth and call for help. As an attending, I have no shame calling for help if I'm unsure of something.”

It's often considered the hallmark of a mature resident to recognize when they are out of their depth and call for help.

And according to Friedman, the questions don’t stop with residency, and neither does the support.

“I was fortunate that when I got to practice, I really was not on my own. I have three fantastic partners who are colorectal surgeons,” she said. “I know that I can always call on them for their opinion. I know that I can always rely on them if I get into trouble.”

Lin said this is characteristic of a physician’s “lifelong journey of learning.”

“We should never feel comfortable about our mastery of a topic,” he said. “Instead, we should always be seeking to improve and be better—to be open and honest about your own gaps in knowledge, and admit when you do not know.”

Sources

1. Personal interview with Robin Friedman, MD. March 19, 2022.

2. Lin, P. Personal interview. March 21, 2022.

3. Pai, J. Personal interview. March 21, 2022.