Resident vs Dr. Almighty -- what to do about potential medical error?
I recently reviewed an interesting 2013 paper entitled, "Transgression confession: Ethics of medical errors disclosure," written by Jones et. al. The article starts and finishes with a surgical case whereby a patient experiences an elevated temperature after surgery, Dr. Almighty (the surgeon) informs the resident not to worry, even though the resident remembered a "break in the operative sterile technique" had occurred. The surgical site became painful, pus "exuded" from the wound, and the patient demanded to know what happened.
The article gives the reader five options to consider for the resident:
A. Keep her mouth shut
B. Tell the patient that would infections just happen
C. Tel the patient that a break in sterile technique was responsible
D. Refer the matter to the chief resident for advice
E. Tell the patient to ask the attending surgeon.
How would you advise the young resident? What should the young doctor do?
The article's authors ruled out options A & B as not ethical or truthful. Option C was not chosen either as we are not 100% sure on the spot that the infection was caused by what the resident witnessed. Fair enough. Option D was dismissed because it is the duty of Dr. Almighty, the surgeon, to discuss questions and issues with his patient. So, E, "Tell the patient to ask the attending surgeon," is the correct answer.
But the article did not give a complete scenario. How should the resident respond if Dr. Almighty refuses to discuss the situation with the patient (or family)? Or what should be done if the Dr. Almighty gives an Option B answer ("infections just happen) and, furthermore, bills the insurance company for treatment to stem the infection? And neither did the paper discuss the technique or methodology for the young resident to refer the patient's original question ("how did this infection happen?") back to the already dismissive and possibly intimidating Dr. Almighty?
This is a great teaching case for residents as well as medical students and nursing students. Invariably, many young clinicians will be faced with a similar scenario, perhaps multiple times, in their fledgling careers. I think medical and nursing students and residents need to be trained on such scenarios, and be made aware of the entire situation. For example, insurance companies and the federal government won't pay medical errors and follow up care from said errors, and knowingly submitting a false invoice is fraud that could have serious criminal consequences. It's one thing to be sued for malpractice, quite another thing to have your liberty put in jeopardy.
It is proper for the patient to be referred back to the surgeon in charge (Dr. Almighty), so long as the resident is trained to have this conversation in an empathic fashion ("I'm sorry the wound has become infected, and you have a valid question. Dr. Almighty was in charge of your operation and let's see what he says..."). But, how exactly should the resident relay the patient's inquiry to the haughty Dr. Almighty? What resources are available to help the resident or nurse with this situation? Can the concern be anonymously reported and then carried forward by an experienced risk manager? Good disclosure programs have infrastructure in place for anonymous reporting ---what about your hospital or nursing home? And what is supposed to be done if Dr. Almighty chooses Option A (keep mouth shut) or B (infections just happen)? The patient must be told the truth, and the young resident or nurse doesn't want to be ensnared in a scenario involving fraudulent billing. At what point is the resident or nurse allowed/encouraged to spill the beans to risk management, or the patient directly? Many moving parts and issues to consider...
Going further, I think this case is a great "interview question" for young physicians and nurses to share with prospective employers. The bottom line question is how will this organization help me -- a young clinician -- through this scenario?
In conclusion, medical and nursing students and residents needs to be trained on this type of scenario. Resources, including anonymous reporting mechanisms, need to be put in place and advertised to staff. Finally, young clinician should pose this scenario to prospective employers.
Doug Wojcieszak, Founder