背景：外科专业的居民在管理医疗危机时面临着陡峭的等级制度。当团队成员不愿发言时，层次结构会对患者安全产生负面影响。然而，以前几乎没有利用模拟来定性探索外科专业居民如何应对这一挑战。本研究旨在探索某外科专业住院医师的经验，妇产科（Ob/Gyn），当挑战等级制度时，目的是告知未来的干预措施，以优化住院医师的学习和患者的安全。
方法：八个3年级和4年级的Ob/Gyn居民参与了一个模拟场景，在该场景中，他们的监督医生做出了错误的医疗决定，危及劳动母亲及其胎儿的健康。居民参加了30-45分钟的半结构化访谈，探讨了他们管理这种情况的方法。三名研究小组成员使用定性主题调查对转录访谈进行了分析，一旦达成共识，最后确定确定的主题。
结果：研究结果表明，模拟情景确实创造了一种对居民提出挑战的等级制度体验。作为回应,居民在面对等级制度时采用了三种不同的沟通策略：（1）信息传递-仅报告现有的临床信息；（2）解释性-故意构建临床事实，旨在摇摆监督医生的临床决策；（3）倡导-准备面对医生的临床决策。此外，居民利用应对机制来缓解与对抗等级制度有关的挑战，即转移责任，减少的紧迫性，起草盟友。当挑战等级制度以保护患者安全时，这些沟通策略和应对机制都塑造了他们的实践。
结论：了解居民在面对等级制度时所参与的复杂过程可以为课程创新的发展和研究提供信息。在这些过程中，我们必须超越仅教居民说话，并考虑更广泛的课程，不仅针对居民，而且针对教师医师和组织内的学习环境。
BACKGROUND: Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The
study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety.
METHODS: Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30-45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached.
RESULTS: Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging - a mere reporting of existing clinical information; (2) interpretive - a deliberate construction of clinical facts aimed at swaying supervising physician\'s clinical decision; and (3) advocative - a readiness to confront the staff physician\'s clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety.
CONCLUSIONS: Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and
study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.
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