The Resident Who Is Not Coping
You are the senior resident on a surgical service. A junior resident, 6 weeks into a 12-week rotation, has been arriving late three times this week, has twice missed a post-operative check, and last night was found crying in the call room at 02:00 after a difficult death on the ward. She says, "I'm fine, I just need to get through this. Please don't tell anyone - I'll be better." She is scheduled for a 26-hour call tomorrow. The attending is on vacation and the service is already short one resident. You have your own 14-hour operating day tomorrow.
1. What is your immediate responsibility to the patient, the resident, and the service?
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Three obligations, in this order: patient safety, the resident's wellbeing, and service continuity.
- Patient safety: missed post-operative checks are a patient-safety signal. Reassign or directly verify the checks she is responsible for tonight. Do not leave a deteriorating patient uncovered.
- Resident wellbeing: her distress is real and she is asking for confidentiality. You can honour the content of a personal conversation while still acting on fitness for duty, which is not confidential. Say: "I'm not going to gossip about this, but I can't pretend I didn't see it, and I can't let you take a 26-hour call in this state."
- Service: you cannot simply absorb her call on top of your own 14-hour day without risking a second impaired clinician. Escalate to the on-call attending or program director tonight - this is exactly what they are for.
Key: you are not the right person to be her only support, and you are not permitted to be the only person who knows.
2. How do you have the conversation, and what resources and escalation do you put in place?
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Conversation (private, non-judgmental, specific):
- Describe observable behaviour, not character: "You've been late three times, two post-op checks were missed, and I found you crying at 2 a.m. I'm worried about you."
- Ask directly about sleep, mood, and safety: "Are you having thoughts of harming yourself?" (Ask - do not assume.)
- Offer concrete options: employee assistance program, physician health program, family doctor, and the option of a reduced or rescheduled call.
- Be honest about limits: "I can keep the details private from your peers, but I have to tell the program director that you're not fit for a 26-hour call tomorrow."
Escalation and supports:
- Contact the on-call attending/program director tonight; arrange coverage for tomorrow's call.
- If she discloses suicidal ideation, do not leave her alone; involve emergency mental health services.
- Document the conversation factually and the actions taken.
- Follow up the next day - the follow-up is part of the intervention.
Key: confidentiality is not the same as secrecy. The duty to protect patients and the duty to support a colleague both require action, and the action is escalation, not silence.