Attending Anesthesiologist Responses to Resident Challenge: The Two-Challenge Rule

Abstract

Introduction: In aviation, the “two-challenge rule” is a principle where a subordinate is obligated to challenge a superior when it’s believed an unsafe action has been taken. If there is no answer, or a nonsensical answer, the subordinate is empowered to escalate the challenge and ultimately take control of the aircraft. A modified two-challenge rule for healthcare has been advocated in patient safety literature where “taking over” is replaced by “calling for help.” In a prior simulation-based study, anesthesiology residents were reluctant to challenge questionable practices of an attending anesthesiologist. This follow-up study examines the responses of attending anesthesiologists to challenges made by residents. Methods: In a simulated operating room, scripted residents challenge decisions made by an attending anesthesiologist (subject). The scenario is an elderly patient (70s) having an elective repair of a humerus fracture under interscalene block and general anesthesia. Relevant past medical history includes hypertension treated with hydrochlorothiazide. While the subject watches from a remote location, a confederate anesthesia team comprised of a simulator faculty attending and resident induce general anesthesia. There is disagreement about proceeding with the operation following discovery that the patient had a small amount of orange juice in the waiting area. After an uneventful rapid sequence induction, the attending is called to another room. The departing attending requests that the subject anesthesiologist supervise the resident described as “difficult to work with.” The patient goes into rapid atrial fibrillation (HR ∼ 150; SBP ∼ 75). Using a structured technique based on the aviation two-challenge rule, the resident challenges medical decisions made by the subject. Videotapes from ten scenarios were reviewed by a single investigator (RHB). Number and type of subject actions and subject response to the resident’s challenge were noted. Subject response was coded to note if the challenge was acknowledged and whether an explanation was given. Acknowledgments were coded as “none,” a “simple” verbal response, or “complex,” meaning the subject acknowledged their management was being challenged. Additionally, the quality of an explanation for the action, or for rejecting the challenge, was coded as adequate or inadequate. The absence of an explanation was coded as inadequate. Results: Of 10 cases evaluated, 45 challenges were identified (average 4.5 per case; range 2–8). Subjects’ choice of therapy for atrial fibrillation was: medical 28/45 (62%), electrical 7/45 (16%), and other 10/45 (22%). 5/10 (50%) of the subjects requested and received help from another attending anesthesiologist. Subject responses to the resident challenges were: none 5/45 (11%), simple 30/45 (67%), and complex 10/45 (22%). The subjects’ explanation to the resident was judged adequate 21/45 (47%) and inadequate 24/45 (53%). Conclusions/Discussion: Anesthesiologists’ responses to resident challenge demonstrated that over half of the challenges were not accompanied by an adequate explanation of the rationale behind the attending’s decision-making. In the authors’ opinions, these are lost learning opportunities for residents. Of greater concern is risk to patient safety when the resident suggestions are ignored or suppressed due to the position of authority of the attending. Conflict of Interest: Authors indicated they have nothing to disclose.