“Hello, I’m John, the surgical F1. I’ve got a patient who is really unwell and I was wondering if you could help me?”
“What do you think is wrong?”
“I’m not really sure. Her blood pressure is low and she seems more confused but I don’t know why.”
“Okay, I’ll be down shortly. Get her observations done again and do an ABC assessment and I’ll see you in about five minutes.”
The junior doctor beside me in the simulation control room turns to me with a look of surprise and says, “You were too easy on him, nobody is that helpful, particularly to someone who doesn’t know what they are doing!”
The Assistance Paradox
I’ve been qualified for over twenty years now and in that time I’ve been at both ends of requests for help on countless occasions. Not only that, I’ve watched others go through the same process too and I’ve noticed a recurrent theme which I have called the Assistance Paradox:
‘The person who is in most need of help is the person least likely to get it’
Think back to your own experiences, particularly on the telephone, when help is being sought and you’ll understand what I’m getting at. When asking for help if you present a case fully, possibly with a nice SBAR structure, you are likely to get a positive response. On the other hand, if you are unsure of the diagnosis, don’t have a clear understanding of the investigations done or the correct guideline to follow, you often have to fight hard to get the desired assistance. The person who is clear, calm and understands what is going on gets help, the one who is confused, uncertain and flustered does not.
Now, there may be all sorts of reasons for this. It may be that you haven’t made it clear how sick the patient is or how much you need help. It may be that the person at the end of the phone is distracted or they are overwhelmed with their own work but, in my experience, I think it comes down to a feeling that you, the referrer, haven’t earned the right to ask for help, you haven’t yet reached a level of competence sufficient to merit assistance. You haven’t taken a proper history or examined the patient properly; you’ve not done the right tests or understood their results; you haven’t asked the ‘right’ person first or followed the correct protocol: any or all of these failings disqualifies you from getting help at this time.
If it were left here that would be bad enough but worse is to come as struggling colleagues are then subjected to a list of their failings together with an admonishment for their actions. If they are ‘lucky’ they are given the answers to the questions they failed to answer adequately, often dressed up as ‘education’, and told to call back when they have sorted themselves and the patient out. Let me ask you, would you call back…anyone…ever?
And so, the person who is most in need of help is not only the person least likely to get it but becomes the person least likely to even ask for it.
What I am saying may seem a little caricatured but it is hard to deny the element of truth that it holds. If you haven’t been through this yet in your career I envy you but most of us who have been around a while have to admit to having been on both sides of that particular experience and consequently we have to ask ourselves some really hard questions. Is this really how we want to behave with each other, is this really how we want to respond to a colleague who is out of their depth, and most importantly, is this really a behaviour we want to perpetuate?
My contention is that the assistance paradox has become an ingrained part of our culture. Don’t believe me? Think of the most popular role juniors want to take on when they do simulations or role play. Is it the helpful surgical registrar or the stroppy anaesthetic consultant, the responsive paediatrician or the obstructive radiologist? Juniors love to turn up to a manikin’s bedside or answer the simulation phone and give a colleague a good grilling: it is almost a rite of passage for them, a form of hazing for the other. It is almost as if they are practicing for their own future behaviour as senior staff… and we must put a stop to it.
Yes, we must train staff to be independently clinically competent but that doesn’t happen on the end of a phone when they are flustered and out of their depth. Teaching people to ask for help in a clear, concise manner is also important but even more importantly, we must engender a culture of being responsive to requests for help. All staff, particularly senior staff, have a responsibility to model this in our daily working lives. This does not mean always attending but it must at the very least mean making the interaction a positive outcome for the caller: helpful advice, useful signposting and a ‘call me back if you get stuck again’ would seem a minimum to me. We must make sure they know that asking for help is a good thing, the right thing and something that we want them to do. We want to be absolutely sure that it is something they will do again because the bottom line is, it is good for patients. Whatever the rights and wrongs of why the person asking for help is asking, the patient they are managing demands you to be helpful, precisely because their doctor doesn’t know what to do! The days of patients coming to harm because staff are afraid to call for help should be long behind us, but sadly this is not the case and it should shame everyone within our profession.
So, when I sit in the simulation control room and am asked for help I aim to give it early and give it easily for the sake not only of the person asking but for the sake of those staff watching on and for the patients they care for.