When Junior Residents Challenge Chief Attendings

Medscape

2 days ago

Life as a medical student is far from easy. Every day, you grapple with a vast course load, erratic shifts during clinical rotations, stress, anxiety, and burnout.
Yet, once you've reached the summit of that academic journey and are conferred with your medical degree, you start your residency, shiny new objects surrounded by much more experienced people.
As a young resident or medical student, the mere idea of disagreeing with an attending physician in a position of power may raise hairs. After all, junior residents and students often look up to attendings, seeing them as versatile healers who can seemingly fix any ailment as they attend to the wards they lead.
As a third-year medical student on call late at night, Suresh Mohan, MD, found himself in disagreement with a senior physician — the chief resident — over the treatment of a patient, which then escalated into an acute emergency.
'I quickly realized [about this senior physician] 'I think you're letting your ego get in the way of doing the right thing for the patient.' That was the first time I disagreed with the way that I watched this person manage something…I realized it was a very human emotion that got in the way of them doing the right thing,' said Mohan.
Bleeding Trachea, Bold Dissent
Mohan is now an otolaryngologist and surgeon at Yale Medicine, New Haven, Connecticut, with a specialty in reconstructive and cosmetic surgery for the face, head, and neck. But the experience he had as a third-year student still resonates with him.
With few people around to help, Mohan found himself relatively alone. 'Sometimes, you're the only trainee in the hospital…the only doctor in the hospital that's responsible for all the patients that need ENT [ear, nose, and throat] care,' he said.
While on call late that night, Mohan and his chief resident were called in on a consult for a patient's bleeding trachea after the patient had undergone a tracheotomy earlier that morning.
During a tracheotomy, a surgical opening is made in the neck and a tube is inserted directly into the trachea. It is usually performed by an otolaryngologist. Bleeding from tracheotomies can range from minor oozing due to irritation or suction trauma to life-threatening hemorrhages if a major vessel is involved.
Upon seeing the patient, the chief resident said there was nothing to worry about and they will continue to monitor the patient. An hour later, Mohan was called again, but his chief maintained that everything was fine.
'Of course, in the back of my head, I'm wondering if it's bleeding more,' said Mohan.
Within the next few minutes, they were called two more times to see the patient, and yet his chief was adamant that no further action needed to be taken at that time.
'Eventually a code was called…we were rushing over there…and it turns out the trach was not fully in the airway,' Mohan said. 'The patient was having trouble breathing and causing more to happen from that…it escalated quickly into a much more acute emergent situation.'
Mohan and the team started yelling for instruments, trying to get the trach tube back in place in the patient's trachea. Fortunately, they were able to secure the airway.
One of Mohan's biggest takeaways from the experience: 'It doesn't matter if they call you three times, you still need to do the right thing.'
Post-Bariatric Bleeding Incident
As a third-year general surgery resident, Joshua Rarick, MD, found himself on call and alone at Covenant Hospital in Saginaw, Michigan. In the late evening during a 24-hour shift, a patient's vitals began to drop following a Roux-en-Y gastric bypass.
Rarick had not personally performed the initial surgery, but as the resident on call, he had to respond to nurses messaging him with concerns about the patient's blood pressure dropping.
'To me, it looked like the patient was probably bleeding, so I had called the attending to update them,' he said.
Rarick tried to temporize the bleeding, but his attending didn't agree.
After a few hours of fluids, during which the patient would transiently respond, eventually the patient's vitals and pressure came back down because she was still bleeding.
'[My attending] disagreed with my plan to go back to the OR [operating room], but eventually we had to go back to the OR because there was a bleeder that we needed to clip,' Rarick said.
Rarick is now a fourth-year general surgery resident. He said these types of interactions aren't uncommon, and not all disagreements end with tempers flaring.
'Sometimes, attendings disagree with you, and they say, 'No, let's do this instead,' which is normal,' Rarick said. 'But that was one of the first times that there was an actual disagreement with what I thought the plan should be.'
Advocating for Optimal Patient Care
As a medical student or junior resident, if you truly feel a patient's case isn't being properly handled, don't be afraid to speak up in a conciliatory manner.
'There are many situations where seasoned attendings are so specialized, their knowledge in other areas of the field might be lacking or just not up to date,' said Mohan. 'So especially as residents who are on top of all the latest info, you have an opportunity to educate, but doing so in a way that's palatable is really important.'
But what if an attending disagrees with a junior resident's or student's concerns, and the latter still feels strongly about the mishandling of a patient's case? In extreme cases where all other resources are exhausted, you'd want to contact a hospital ombudsman, clerkship director, site director, or even faculty mentor, said Mohan.
'If there's something egregious happening, and the resident or student doesn't feel comfortable approaching in a direct format, ombuds people are able to report a concern,' he said.
Mohan listed an order of resources to consult before this, however. 'First, look it up to understand if your question is reasonable. Two, talk to a resident to try to get some more knowledge. Then, if you're still not feeling comfortable, and gently assuming that the attending is not receptive, I think finding other faculty mentors is probably the next place to go. And if you're really feeling lost, then contact an ombudsperson.'