This blog post was originally published in SAEM Pulse, July/August 2020.
When I was a junior resident, a male attending told me during post-shift feedback that he noticed I did a lot of my own work. He saw me getting repeat vital signs on patients, fetching them water and blankets, gathering supplies to perform simple procedures like laceration repairs, and delivering transferred patients’ imaging discs to radiology. He told me that delegating these tasks to technicians, coordinators, and nurses would be crucial in transitioning to a senior resident and attending.
I appreciated the advice: with increasing patient volume, it wouldn’t be efficient or feasible to perform every task, clinical or non-clinical, for every patient.
However, in my experience up to that point, requesting help from staff in the department usually led to responses directing me to do the tasks myself.
As an emergency physician in training, I rotate across four hospitals, each of which has variable availability of support personnel and distinct expectations of what is within the purview of each staff member in the emergency department. Even across these practice settings, my experience as a junior resident was the same. Despite my strategic and polite requests for help from staff who seemed otherwise unoccupied, they often deflected.
Quickly, I stopped asking for help and found it faster and easier on my relationships to accomplish tasks on my own.
Though I observed that male attendings’ requests were often honored, I initially assumed the differential responses were due to my position as a junior trainee: I was a new face and a fledgling doctor—what could I expect?
When I turned to female co-residents, both within my residency program and at others, however, our collective experiences suggested gender influenced our abilities to delegate. Some shared experiences of witnessing ED staff support male co-residents and consultants with tasks without being asked—for example, bringing gauze and saline to the bedside for a bleeding patient, or prepping and positioning a patient for a procedure with lidocaine at the ready. We all noted that as female physicians, we had learned to minimize our requests for help, and when we did dare ask for assistance with tasks, we couched our questions in apologetic language—“I’m so sorry to bother you”—or qualified them—“if you’re not too busy with something else.” My female co-residents had received the same feedback about delegating from male attendings, and similarly felt the advice was impractical.
I turned to female physician mentors for advice. Here is how they responded.
Why does it seem harder for female physicians to delegate tasks in emergency medicine?
Dr. Regan Marsh, Brigham and Women’s Hospital:
“I highly recommend the FemInEM talk by Nick Gorton, a transgender man who practiced EM as both a woman and now as a man. He described it as switching a video game from the ‘hard’ to the ‘easy’ setting. For me, the most provocative and important part is around minute 6:00 in the video, where he talks about societal traits traditionally associated with men and women (achievement vs. communal oriented), and how concordance/discordance with these expectations often results in women physicians being perceived as ‘bitches’ and kind men end up as saints.”
Dr. Onyekachi Otugo, Brigham and Women’s Hospital:
“Delegation is something that is expected from our male colleagues and is often questioned when coming from women. However, it is often difficult for women to often delegate because we are worried about how we may be perceived by others—whether we will be seen as unfriendly, overly aggressive, or whether our orders questioned. Regardless of how uncomfortable these situations might make us feel or how we will be perceived, delegation allows for efficiency and ensures that our patients are receiving the best care possible.
In addition to delegation, it is often essential to know when to step in. For example, in a situation where there is a critical patient that needs bloodwork and has had multiple failed IV attempts, instead of waiting to be asked to assist in obtaining access, a critical step is taking the initiative to grab an ultrasound and placing the IV. This requires situational awareness—stepping in without being asked. Situational awareness is just as essential as being able to delegate.”
How do you navigate the dynamics of asking for help with simple but time-consuming tasks?
Dr. Onyinyechi Eke, Massachusetts General Hospital:
“I trained at a county program where you had to do things yourself: wheeling patients to x-ray, getting patients supplies, blankets, and sandwiches, and many times even discharging the patient, removing the IVs and so on. I had to learn names and be respectful. At Cook County, most of the nurses and technicians looked like me and were minorities. A number of them even spoke my ethnic language. With limited resources and high patient ratios, I knew they were busy and overwhelmed. As I progressed through residency, those nurses and techs became my lifeline during acute/trauma cases and gave me a break during simple cases.
Now in a new environment as a new attending, most of the nurses look very different from me and have different life experiences. I have also found it important to learn names, be respectful and additionally, be firm. Do I notice that sometimes male colleagues get things done for them faster? I do. Are there multiple factors at play? Of course. Even so, I trained well and relationships take time to grow/change.”
Dr. Susan Wilcox, Massachusetts General Hospital:
“I frequently do many of these things myself as well! I cannot remember ever asking a technician or nurse to gather supplies for me. Ever. In fact, I can recall numerous times when I have asked for help with issues that fall strongly within their purview, not mine, and still being told to do it myself. I too find it to be a pleasant surprise when someone volunteers to help - and I’m a PGY 17. The way I’ve navigated these dynamics is that... I don’t. I’ve decided that being liked by nurses and technicians gains me more long term than getting help in the short term. I think this highlights the chasm between our experiences, even working in a couple of fairly enlightened departments.”
What are your strategies for successfully delegating?
Dr. Kelli O’Laughlin, University of Washington:
“Learn names of medical assistants and nurses
Ask the right person to do the right thing. If you need a sandwich for a patient, try to ask the technician and not the nurse.
Sometimes, if I am sensing resistance, I give enough explanation to justify the mission, i.e.: ‘I need your help. I have a few competing demands right now but our patient really needs us to address his nose bleed promptly. I need you to find the ENT cart and bring it to Room 10. Can you do that?’
If they cannot, ask them who they recommend you request help from--especially if one medical assistant is busy, which one is assigned to that pod? They often know better.
If the nurse cannot do an urgent task, I ask the charge nurse who is available to do it. This is more often needed for critically ill patients or if there is a delay to admit someone.”
As I start my last year of residency, my own approach has become an amalgamation of the above. It has indeed become easier to delegate with more clinical experience and longer-standing relationships. Yet my approach to delegation remains cautious. If I don’t feel strapped for time, I try to do everything myself.
I limit my requests to moments of great need—typically with a critically ill patient. I continue to do my best to learn all my colleagues’ names. And I still personally get plenty of water and warm blankets for my patients.
Delegation is a crucial skill in emergency medicine, even if we take different paths to get there based on our social identities. I am always deeply appreciative of receiving help and will never take it for granted.