Insights on Residency Training
Published September 19, 2017
The following is a case in which a medical error occurred. The goal of this discussion is to evaluate the role of conflict, how it contributes to medical decision making and how early identification of conflict and its causes can optimize patient outcomes.
I see that you gave Mr. Mercier steroids, which is going to compromise our diagnostic workup. What happened?
Mr. Mercier is a 55-year-old man who presented with a 6-week history of persistent fevers, weight loss, and fatigue. He is admitted overnight to a general medical ward at St. Elsewhere Hospital after an unrevealing outpatient evaluation. During morning rounds, the team decides to call a series of consults. The following are the perspectives of Nina (the intern), Sam (the consult resident) and Abby (the Oncology fellow) recalling the sequence of events over the course of the day.
After morning rounds I paged the Rheumatology, Infectious Disease and Oncology Consult teams about Mr. Mercier; Rheumatology and ID called me right back and we discussed the case and subsequent work-up. I didn’t hear back from Oncology so I paged again and then ran to lunch. After lunch my co-intern signed out his pager to me so he could go to clinic. One of his patients, Ms. Dorfman, was admitted with a urinary tract infection, and had been hypotensive earlier in the morning. I was on my way to check on her when I heard my name announced overhead, it was Oncology finally calling me back.
I picked up the phone and heard the voice of Sam Brown on the other end. Immediately I felt my heart start to race. “This is Sam calling you back from Oncology about a patient Mercier.” Sam was my supervising resident last month in the MICU; let’s just say it was a challenging month. Sam seemed more interested in talking about papers than helping me take care of patients and early on we often disagreed when discussing management plans. In one instance, Sam wanted to get a CT scan on a patient and I advocated not to get it; later we found out the patient had a pulmonary embolism. Sam and I never discussed our disagreement. After this I felt uncomfortable expressing my opinions and did my best to avoid discussions with Sam.
I told Sam the details of Mr. Mercier’s case that I heard on morning rounds. Sam’s first question was if the patient had lymphadenopathy on exam. I didn’t know the answer; the overnight intern did the exam that morning. Sam then launched into an overview of the differential diagnosis on the phone. “Have you asked ID and Rheumatology to see the patient? This could be a lot of things. Are you writing this down?” While on the phone I received multiple pages, one informing me that Ms. Dorfman’s blood pressure was back down to 85/55. Sam was still talking when a nurse approached me about an order for another patient; I found myself only half listening to either of them. Sam asked me to order a lactate dehydrogenase and give Mr. Mercier steroids in case this is lymphoma. Finally, Sam stopped talking; I hung up the phone, put in the order for steroids on Mr. Mercier, and ran to see Ms. Dorfman.
Sam (Oncology consult resident):
I woke up in a panic realizing that I overslept and would be late for my first day as the Oncology consult resident. I had just finished a difficult month in the MICU and was looking forward to working with Abby, one of the senior Oncology fellows known to be a great teacher. I am applying to Oncology fellowship, want to learn as much as I can, and make a good impression.
I arrived 45 minutes late to Abby’s office and tried to apologize for being late. I didn’t know if she heard me, but she asked me to return 3 new consult pages. The last page was from Nina, who was on my MICU team last month. I felt awkward calling her back. Our interactions toward the end of my month in the MICU were strained; I sensed that Nina wasn’t particularly engaged in patient care.
After hearing from Nina about Mr. Mercier’s presentation, I thought he needed an expedited work up for lymphoma. The case sounded really interesting; I looked forward to discussing it with the rest of the oncology team. But Abby was in morning clinic with a full schedule and the attending was giving a lecture to the medical students, so I felt as if I were running the service alone. Thinking ahead to the potential need for biopsy, I asked Nina if the patient had any lymphadenopathy and was surprised to hear she didn’t know. I couldn’t believe Nina had not examined the patient before calling the consult. I didn’t want to interrupt Abby in clinic, so I recommended a few tests to Nina to send on Mr. Mercier, including a serum LDH. I tried to do a little teaching with Nina about the need to avoid steroids for patients with suspected lymphoma, but she seemed disinterested. After hanging up with Nina, I returned the next new consult page.
Abby (Oncology Fellow):
Halfway through my second clinic patient of the morning Sam finally showed up. I already had three consult pages waiting for me, which I forwarded to Sam. I knew Sam was interested in Oncology and I hoped that might be helpful given how busy the day was shaping up to be.
In the afternoon, with 6 clinic notes still to finish from the morning, I met Sam and my attending to round on Mr. Mercier. As Sam was presenting the case, my attending called our attention to a note from the primary team indicating that a dose of steroids was given at the recommendation of the Oncology consult service. The attending looked annoyed and asked me how this happened, emphasizing how steroids will obscure biopsy results, complicating making a diagnosis. I would never have recommended steroids; how could Sam have made this recommendation without talking to me? Perhaps I should have supervised Sam more throughout the morning, but I just didn’t have time.
I saw Nina, the intern, sitting at the work station, so I figured I would just clarify this directly with her. “I see that you gave Mr. Mercier steroids, which is going to compromise our diagnostic workup. What happened?”