Recognising juniors’ inculpability for mistakes reduces the risk of unfair scoldings. To this end, we propose: the HOPELESS test.
Face it. Getting scolded is part of the physician’s life. The whole spectrum of our society goes through it: the HO who falls asleep on call, the MO holding the laparoscopic camera upside down, the Registrar who should have known better than he does, or even the Consultant whom senior management doesn’t like very much.
Those of us who are sensible will find common ground on the fact that scoldings are not inherently bad. Recall a singular mistake you invariably made as a junior, one which you would consider unforgivable today. Think about why you feel so strongly about it. Half of it at least is personal guilt, but the lashing you got from your bosses afterwards likely helped a lot to brand it into your memory. And it’s all for the better, because you never did it again.
Yet, more than these, we can remember times where we have been unfairly scolded by a senior. On top of bad food, worse hours, suboptimal remuneration, and having to grind through a residency for a shot at professional glory, this is one of the more demoralising things about Medicine. The change in culture away from these unjust realities must start with us — how we look at things and how we react to them.
How can we optimise scoldings? We mean, of course, how to ensure that scoldings are only given fairly, and are certainly not hoping to increase the total number of scoldings in the profession for no reason. More is not always better, though it may be at times that both are necessary.
Pertaining to this discourse, we shall define a “scolding” as an issuance of criticism to an individual relating to a matter of professional fault attributed to him/her. We should not confuse it with bullying, which is systematic aggression towards a target individual resulting in said individual feeling threatened or humiliated. Bullying is destructive, and intrinsically bad; scolding is, per its telos, constructive, and therefore intrinsically good.
A scolding can be conveyed in person, or over any form of communicative media (c.f. the Tigertext sticker pack). Barbed or vulgar language is fair game, as all physicians ought to be free to creatively express their thoughts and feelings, though the power of special vocabulary should be applied with prudence. Personal attacks are not altogether excluded (c.f. “motivational” quotes from surgeons) but should have reasonable cause, for example, if the same physician is being scolded for the same thing over and over again.
Because the spectrum of scoldings is so wide, we propose we first focus on the most basic these, that is, HOs getting scolded by MOs. This category comprises the largest number of scoldings in public hospitals (at least, between the months of May and August). Furthermore, the potential for bullying in this category is ameliorated by the fact that MOs typically do not have the power to take substantive punitive action against HOs, hence ensuring that the scolding is, indeed, just a scolding.
We propose a simple point-of-care algorithm called the HOPELESS (House Officer Prediction of Error LEading to ScoldingS) test. It relies on a short battery of 3 simple questions which are short enough to fit in a feisty MO’s lock screen, or, for the more adventurous, to fit inside a forearm tattoo. The inclusion criterion is essentially any situation in which a reasonable MO might be led to believe that a HO needs to be scolded. In turn, the MO can be judged reasonable if the MO’s opinion is internally consistent and logical, and other respected peers of said MO support this opinion (c.f. the Bolam-Bolitho test). In short, any MO about to scold a HO may apply the HOPELESS test.
The questions in the HOPELESS test are:
- Was the situation practically avoidable?
- If so, was the issue directly consequent to a deficit in attitude, knowledge, and/or competency?
- If so, did the issue cause, or present risk of, significant harm?
The HOPELESS test aims to detect situations in which a HO should not get scolded. Conceptually, the answer to each question addresses a critical factor in the validity of the scolding, which respectively are:
- Practical unavoidability of the situation — that is to say, there is nothing the HO could have done to prevent it.
- No professional cause for blame — even if the HO could have done something to prevent it, it cannot be a failure of attitude, knowledge, and/or competency, which we believe encompass reasonable professional expectations of any physician.
- Lack of real present or future harm — though ends do not justify means, there are still situations which are obviously superfluous from head to tail, and these need not be seriously addressed.
It’s easy! If the above conditions are met, then the HO should not be scolded. It is geared toward specificity over sensitivity, so only HOs who are far in the clear with escape a scolding. But does it make sense? What better way to test it than a (for all intents and purposes, completely fictitious but very realistic) case series! We’ll start with the simple, and move on to more nuanced scenarios.
CASE 1
One of the ward HOs in your Orthopaedics team keeps coming late to work: to be precise, between 8 to 9 in the morning on average. The other HOs reveal that this is not the first posting this has happened. It is not unheard of that they have to cover for her during the absent hours by preparing her notes, presenting her patients on rounds, or even seeing CTSPs from her patients. The HO, when questioned, feels perfectly fine about this behaviour, and defends it by saying that it was allowed in previous postings.
Was the situation practically avoidable? Yes. It is always possible to come to work on time. Junior physicians of every rank should do this, and having anticipated no changes to do is not an excuse, as free time should be used to help other colleagues in the same team.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Yes. This is a clear-cut attitude issue.
Did the issue cause, or present risk of, significant harm? Yes. There may be no great consequence if there is an abundance of manpower and a small number of well patients. But there is never a guarantee of this in virtually any inpatient team.
Case 1 fails the HOPELESS test with flying colours. This HO should not escape a scolding.
CASE 2
One of your geriatric aunties admitted for severe gastroenteritis went borderline hypotensive at around 5 in the morning. The Gen Med HO on call attended to the case, evaluated the patient, and decided, understandably, to trial a fluid bolus. The problem was that the HO gave the patient a fast bolus of what she was already on for maintenance: a pint of Dextrose and Potassium, over 30 minutes. Thankfully, by the time of your morning review, the patient is doing well and has become normotensive again.
Was the situation practically avoidable? Yes.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Yes. The HO had either failed to recall that a Potassium-drip should not be given as a fast bolus (competency), or did not know this at all (knowledge).
Did the issue cause, or present risk of, significant harm? Yes. It could have triggered an arrhythmia, or even cardiac arrest, in a frail partially-coded patient. It did not matter that there were no actual complications.
Case 2 also fails the HOPELESS test. In this case, the HO would benefit from a gentle scolding which corrects the knowledge error, as he did act appropriately otherwise.
CASE 3
A middle-aged male has been admitted to your Gen Med ward overnight for pyelonephritis. On reviewing the notes upon your arrival to work, you are horrified to find that, shortly after reaching the ward, the patient became lethargic, hypotensive, and tachycardic, and his temperature never went below 39 degrees after that. Though the patient was briefly seen by the MO on call for the admission review, every subsequent note was signed by the HO. Essentially, the HO had attended to the patient because he was severely hypoglycaemic, and the MO on call wanted random serum glucose measurements to confirm this before each bolus of Dextrose. As the patient was peripherally collapsed, the HO had to obtain the bloods via femoral sampling, and no less than 5 of these were performed since the patient’s arrival (including the admission bloods and cultures, also sent by the HO). The HO documented multiple discussions with her MO regarding the possibility of escalation to HDU, but it appears that the MO favoured keeping the patient in the general ward instead. You scramble to see the patient, who is obviously still in septic shock, and looks the part too. After an early Reg review, the patient finally gets on his way to MICU.
Was the situation practically avoidable? Yes.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? No. A HO receiving orders from her MO is ordinarily obliged to follow them. Contrary to a rich literature review of medical dramas, we believe that being a cowboy in front of your senior is professionally suicidal, and it is reasonable for any junior to believe that it is not worth the risk.
Did the issue cause, or present risk of, significant harm? Yes, the patient was evidently harmed. But because of the preceding factors, this part is irrelevant to the conclusion.
Case 3 passes the HOPELESS test. It is clearly unreasonable for this HO to be scolded. There is room to explore if HOs who disagree with their MO’s plans, especially in these high-stakes situations, should always escalate to a Reg level. Few, if any, would dare, and chances are that the majority of these would be in the wrong anyway.
CASE 4
One of your surgical HOs has taken an affinity to teaching the new SIPs attached to your team. Unfortunately, her quality of work has not kept up with her eagerness. One of your new patients, a young asthmatic NSF with abdominal pain and an intermediate Alvarado score, has been listed for a CTAP in 4 hours’ time. As per Radiology’s instructions, he will require a 20-gauge IV cannula and premedication with a Hydrocortisone bolus. The HO brings the SIPs to see the patient: she will let them set the cannula, and she will push the Hydrocortisone afterwards. After a period of silence, you pass by the patient’s bed 2 hours later to find that the patient still has no cannula after multiple tries, and the Hydrocortisone has not been given, putting the CTAP timing in jeopardy. The HO in question is in a nearby tutorial room, still giving the SIPs feedback on how they should perform IV cannulation.
Was the situation practically avoidable? Yes.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Absolutely. A HO’s desire to teach is commendable, but it should never come at the expense of work being done. Inability to prioritise is just a higher form of incompetency.
Did the issue cause, or present risk of, significant harm? Yes, and even more so if the patient were sicker. The further harm here is that a CT slot has been wasted.
Case 4 fails the HOPELESS test. The HO in this case would need to be firmly told to get her work in order, and find spare time after hours for her teaching opportunities.
CASE 5
A medical HO on call does not attend to a CTSP for desaturation as he did not pick up his phone when texted, and then called, by the nurse. The ward sister only alerts the MO 30 minutes later, by which time the already-sick patient is cyanotic and in respiratory distress. The patient receives an escalation of antibiotics and a trip to a high dependency bed for non-invasive ventilation. The HO, all this while, was trapped in an isolation room setting an IV cannula and taking bloods for a haematology patient’s neutropaenic fever workup. He was unable to pick up his phone because he could not breach aseptic technique, the junior nurse supposed to assist him in the room had spent most of her time outside of it despite his protests, and the procedure was prolonged because of difficult vascular access.
Was the situation practically avoidable? No. The HO had taken reasonable steps to prepare for the procedure. As the patient was previously unknown to him, he could not have expected particularly difficult veins. Once the procedure had begun, he would have been unable to breach technique to answer it, and would have relied on his assistant to help him pick up the phone instead. Furthermore, neutropaenic sepsis is a high-priority review, and the HO had done well to attend to the patient urgently.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Irrelevant, because the situation was unavoidable.
Did the issue cause, or present risk of, significant harm? Also irrelevant, because of the above.
Case 5 passes the HOPELESS test from the get-go. Within the bounds of realism, there is little the HO could have done differently to prevent this issue. It would be unfair for him to receive a scolding.
CASE 6
An obstetric HO on call receives a CTSP for hypertension. The patient is a 39-year-old being monitored inpatient for a tiny antepartum haemorrhage at 36 weeks’ gestation, and she also has Pregnancy-induced Hypertension on regular Labetalol. Now her SBP is in the 180s and she’s thrown up her dinner. The HO, instead of seeing the patient, escalates to her MO immediately, and waits for the MO to come, while the MO remains unresponsive because the ED queue has not been kind to him. The MO finally replies after a while and instructs the HO to review the patient, send off investigations, and to serve a dose of “Adalat” (Nifedipine) — unbeknownst to him, the HO ends up serving the patient the long-acting formulation of Nifedipine instead of regular Nifedipine as he had intended to convey (and in accordance with the department’s protocols and parlance). The MO only corrects this mistake afterwards when he reviews the patient’s notes himself and discovers that her BP has not been controlled for over 2 hours.
Was the situation practically avoidable? Yes. As any M4 student would know, any obstetric patient with hypertension and red-flag symptoms for severe pre-eclampsia requires an urgent review, with blood and urine tests to be ordered.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Yes. This case is multifactorial: neglecting to review the patient is secondary to terrible knowledge at best and terrible attitude at worst, and relative incompetency led to the prescription of the wrong medication which would have been ineffective in the acute management of the patient’s condition.
Did the issue cause, or present risk of, significant harm? Clearly. In all obstetric centres, the management of hypertension is highly protocolised, and early management can be initiated at any level. Any delay in care is harm done to not 1, but 2 patients.
Case 6 fails the HOPELESS test miserably and without excuse.
CASE 7
A surgical HO, not on call, has had a wonderful night out clubbing. The problem is that he has to do a weekend round the following morning. Having consumed enough alcohol to land any lesser creature in an ambulance (though he admittedly is not just any lesser creature), he decides, at around 3 in the morning, that he will just go directly to the hospital to save 2 rounds of Grab fares. He finds an empty call room and crashes out inside of it. He wakes up in the nick of time come morning, pre-clerks his list before the start of rounds, survives rounds itself, and battles through 3 hours of changes, including a few sick CTSPs, all the while sporting a splitting headache from the hangover.
Was the situation practically avoidable? Yes.
Was the issue directly consequent to a deficit in attitude, knowledge, and/or competency? Yes. Astoundingly. Unnecessarily spending a night in the hospital is a poor life choice. Some surgical gunners may protest but they still know it’s the truth.
Did the issue cause, or present risk of, significant harm? No. As long as the HO had consciously limited his drinking with the expectation that, either way, he would need to report to work later, and was indeed able to discharge the needed duties at work, there would be nothing he is culpable for.
Case 7 passes the HOPELESS test by a hair. Why scold? It’s honestly impressive.
Thus, our limited case series comes to an end. We are sure that there are many other stories out there, that not all the books in the world could contain them. Which means that there is far more space for everyone to play with the HOPELESS test, and to provide end-user feedback on it.
Those of us who paid attention in our Medicine and Law tutorials may rightfully ask: why don’t we just judge the HO using the Bolam-Bolitho test? To which we reply: that would indeed be ideal. However, the Bolam-Bolitho test is best applied in formal legal proceedings where the HO’s soundness of logic can be tested, and a panel of the HO’s peers can be deposed. We observe based on experience that matters rarely escalate to such a level, except perhaps in a certain large maternity hospital and its frequent fact-finding missions. The HOPELESS test, on the other hand, is a spot test which can be conducted in the few seconds to minutes a MO realistically can spare before finding and scolding the HO, either during the shift itself, or shortly after.
Unnecessary scolding of HOs is a huge problem, a dragon which easy-to-use frameworks like these can aid us in slaying. So try out the HOPELESS test and let us known how it goes! With greater recognition, it may even achieve MDCalc status, allowing us to export our top-down approach to scolding optimisation around the world. Possible vertical expansion for the HOPELESS test may include a similar one which can be used in OT to protect innocent MOs from angry seniors… perhaps, the MONSTR (Medical Officers Needing Surgeon Tantrum Rescue) test?
on room air 
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