A Trainee in Difficulty: Feedback, Documentation, and Duty to Report
You are the supervising resident on a general internal medicine rotation. A first-year resident, Dr. A, has been on the ward for 3 weeks. You have noticed that she arrives late 4 of 7 days (10-25 minutes), has twice failed to document vital signs on sick patients, and last night did not escalate a patient with a new heart rate of 130 and BP 88/50 until 90 minutes after the nurse paged her. When you raise it, she says, 'I'm fine, I just need to be left alone - my father is dying and I'm his only caregiver. Please don't put anything in writing, I can't afford to fail this rotation.' She is otherwise knowledgeable and well liked by patients.
1. What are your immediate patient-safety priorities, and how do you separate them from the trainee-support question?
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Separate the two tracks explicitly, because conflating them leads to either unsafe silence or punitive overreaction.
Immediate patient safety:
- Confirm the patient with the missed escalation has been reviewed and is stable; document the review.
- For the current shift, ensure Dr. A is not solely responsible for unstable patients. Pair her with a senior or redistribute the sickest patients for now. This is a temporary, supportive measure, not a punishment.
- Set a clear expectation for escalation: any patient meeting early-warning criteria is escalated immediately, and the nurse can bypass her to you if there is delay.
- Tell the nurse that escalating directly to you is appropriate and welcomed.
Support track:
- Acknowledge her disclosure about her father with empathy and without making it the whole conversation.
- Ask what support she needs (flexible start times, counselling, employee assistance, leave options).
- Explain that support and accountability are not opposites: you can help her and still have to act on safety concerns.
Documentation: you cannot promise to keep safety concerns out of writing. Say so kindly: 'I can't promise that, and here's why.'
2. She asks you not to document. What do you say, and what do you document?
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What to say: 'I understand why you're asking, and I'm not trying to end your career. But I can't promise not to write this down. If something happened to a patient and there was no record that I knew about a delay in escalation, that would be worse for the patient and for both of us. What I can promise is that I'll write it factually, that I'll include the context you've told me, and that I'll tell you what I'm writing and give you a chance to add your perspective.'
What to document (objective, behavioural, dated):
- Specific observed events with times: late arrivals (dates/times), missing vital-sign documentation (which patients, which dates), the 90-minute escalation delay (time of page, time of response, vital signs).
- Actions taken: patient reviewed, findings, plan, redistribution of workload.
- The conversation: that concerns were raised, her response, and her disclosure of her father's illness - recorded respectfully and only to the extent needed for context and support planning.
- The support offered and her response.
- That the concern was escalated to the program director per policy.
Do not document speculation about her character, her personal life beyond what is relevant, or opinions ('she doesn't care'). Use quotes where possible. Give her the opportunity to respond in writing if she wishes.
3. What are your obligations to the program, and how would you frame the feedback conversation?
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Obligations:
- Escalate to the program director and, per local policy, the residency training committee. Repeated late arrival plus a failure to escalate a deteriorating patient are competence and professionalism concerns that must be on the record; a remediation plan needs to be formal, documented, and shared with her.
- Do not wait until the end-of-rotation assessment to raise it; early, specific feedback is fairer and more effective.
- Ensure the remediation plan is proportionate, time-bound, measurable, and includes support (counselling, adjusted schedule, mentorship).
- Consider whether a leave of absence or reduced duties is appropriate given her caregiving burden - this is a supported option, not a penalty.
- Protect confidentiality: share only with those who need to know.
Framing the feedback conversation (e.g., using a structured model):
- Set the scene: private, scheduled, enough time, no interruptions.
- Start with specifics, not labels: 'On Tuesday you arrived at 07:25 for a 07:00 handover. On Thursday night the nurse paged you at 02:10 about a heart rate of 130 and BP 88/50, and you reviewed the patient at 03:40.'
- State the impact: 'That delay put a deteriorating patient at risk.'
- Ask for her perspective and listen.
- Agree on concrete expectations: on time for handover, escalation within 10 minutes, documentation of vitals, and a weekly check-in.
- Offer support and name the consequences if the plan is not met.
- Summarise, confirm understanding, and document.