“With great power comes great responsibility…” – Stan Lee
‘Tis the season of transitions. This summer marks the annual promotion day for most medical professionals. We transition between junior to senior, from clerk to resident, from resident to new attending. And with this comes increased responsibilities, including teaching.
This month, we ask you to come and help us think through a difficult situation that might occur between various levels of learners and supervisors.
MEdIC Series: The Concept
Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in pdf format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.
The Case of the Justified Junior
by Ms. Eve Purdy (@purdy_eve) & Teresa Chan (@TChanMD)
It was 6:30 am on a typical Wednesday morning in April. The department was finally getting under control, and Samantha the PGY4 resident surveyed her Emergency Department tracker board with pride. Her attending, Dr. Wittenburg, had challenged her with ‘running the department’ that night. Sure, Dr. Wittenburg had been around to review, but seeing as Sam was only a mere 3 months away from becoming an independent practitioner, she had observed and supervised but had seen very few patients on her own. Just the way that Sam liked it.
“If only I didn’t have that clinical clerk with me, then this board would be perfect,” thought Sam, as she noted one last patient who he had yet to disposition…
Sam sighed just thinking about having to go and talk to her. Thus far, she had avoided all contact with Mrs. Kim, pawning her off on the medical student. She’d been trying to let Mike, the clinical clerk, call the shots on ‘his’ patients. He was a 4th year medical student, newly matched to their residency program. But now, it was time for Sam to set things straight and get Mrs. Kim out of ‘her’ department.
“Ok, Mrs. Kim, so the plan is that we we’ll call your son and he’ll come pick you up right?” yelled Sam towards Mrs. Kim, trying to wake her up.
Mike was somewhat taken aback at Sam’s sudden involvement with Mrs. Kim. Sure, he had been reviewing with her all night, but Mrs. Kim had been his patient initially. Now, it seemed that Sam was taking over.
Mike fidgeted impatiently, waiting for Mrs. Kim to sit up. She was a fragile looking 69-year-old lady who was cocooned within several blankets on a stretcher in the hallway.
Mike had noted throughout the night and during his frequent reassessments that Mrs. Kim seemed to be very ‘off’ last night, and had pleaded with Sam to let her stay for a few hours of observation. Sam had reassured Mike that she knew Mrs. Kim quite well, since she was a frequent visitor in their emergency department.
Earlier in the shift, Sam had explained in detail the frequency at which Mrs. Kim would come in, and regaled Mike with stories of the more trivial visits – like when she came in for a paper cut because she, apparently, had run out of bandages at home. However, it seemed like Sam was getting more and more impatient as the night shift progressed.
“But… Dr. Sam… I really don’t want to bother my son. Can’t you wait just a short while longer?”
“No. You’ve been here all night,” Sam stated firmly. “I’m calling your son.”
And with that she threw down the chart marched towards the unit clerk’s desk to call Mrs. Kim’s son.
Mike started to follow, at first assured by Sam’s confidence, but then he couldn’t help but stop midway down the hallway and look back at Mrs. Kim. There was something that didn’t feel right. Like many medical students, Mike didn’t know exactly what was bothering him. Was it the unanswered and unclear reasons for Mrs. Kim’s repeated visits? Had anybody asked her why she kept coming back to the ED or did they just patch her up and send her home. Was it Mrs. Kim’s reluctance to call her son? She knew that if his mom was in the ED all night he would want to know. Or maybe it was just her eyes. She looked sad – but just about everyone looks sad in the ED.
Mike knew he had to say something. Before Sam could pick up the phone he muttered: “Something’s not right, I don’t think we should call him. She shouldn’t go. I don’t know why… just a gut feeling.”
Sam shook her head thinking about the long 4 years ahead with Mike in their training program if every ‘frequent flier’ interaction was like this. She replied, laughing: “You are going to have to do better than that. I need more than your gut feel here because my gut tells me this is just one more of her ridiculous visits. My gut trumps your gut. She’s going home.” She picked up the phone and asked Mr. Kim to come by and pick up his mother.
Mike found himself fuming, but knew as a clinical clerk there was an unsaid rule that you could not question the senior resident. Instead, secretly feeling unrespected and frustrated, he took his leave of Sam, mumbling about needing to go to the bathroom. En route, he became more angry at himself: Why hadn’t he been able to advocate for his patient more eloquently? He thought about going over Sam’s head to their attending, but quickly disregarded that thought. Dr. Wittenburg would most likely just laugh at him like Sam had just done. Instead, he just shook his head in frustration before before dousing his face with water and exiting the bathroom.
Defeated, he emerged from the washroom… and found Dr. Kathy Wittenburg standing in the hallway.
“Oh, Mike! Sam told me I might find you here,” she said, a wide smile on her face. “I brought you a coffee and a cookie… Thanks for all your hard work last night. Sam said you did a good job!”
“Oh… thanks,” Mike said as he half-heartedly took coffee cup from the all-too-chipper attending physician.
“Is everything ok, Mike?” inquired Kathy. She had noticed that Mike had sulked out of the washroom and his hair was a bit of a mess – tell-tale signs of the frustrated medical student.
Dr. Wittenburg sat down on the bench in the hallway and motioned for Mike to do the same.
“What is it?” she asked Mike gently. “Was Sam being hard on you last night?”
“Well…” Mike was hesitant to continue. He didn’t want to get a reputation as a tattletale. He was about to start residency in this program, and he had hear that Sam also had been hired as an attending starting in July.
“Well….You know, Mrs. Kim?”
“Yes, of course.”
“I told Sam that there’s something going on with her, but I can’t quite put my finger on it… But, she says Mrs. Kim is here all the time for little things… I’m sure she knows better than I do… But, I don’t know… I just feel like there’s something else.”
Sitting back, Kathy surveyed the young resident-to-be and pondered the scenario.
Kathy had interviewed Mike for her residency interviews just a few short months ago, and recalled the fantastic sense of empathy that Mike had displayed at the time. She remembers thinking that the only downside to his empathetic spirit was that Mike might run into issues with getting overly involved with patients.
On the flip side, Sam was sometimes quick to jump to conclusions. An excellent diagnostician and proceduralist, Sam had needed coaching on interpersonal skills when she was more junior. She had worked hard and had overcome these, but last night Kathy had charged her with a lot of responsibility. Was this affecting her judgement?
“Hmmm… Seems to me that there’s a difference of opinion around Mrs. Kim’s case,” she reflected. “In that case, why don’t I wander over there and poke my head in and see what my ‘spidey sense’ tells me.”
- When is it ok to ‘question’ authority or raise concerns?
- How do you encourage med students to speak up?
- How do you respond when you receive a ‘challenging question’ as an attending or supervising resident?
- How do you debrief a situation when a learner is ‘wrong’?
- As an attending or senior resident, how do you admit when you are wrong?
Weekly Wrap Up
As always, we will post the expert responses and a curated commentary derived from the community responses one week after the case was published. This month the two experts are:
- Dr. Megan Ranney (@meganranney) completed EM residency and fellowship (in Injury Prevention Research) at Brown University…and 10 years later, has yet to leave! She is founder and director of the Brown Emergency Digital Health Innovation program, and Associate Professor in the Dept of EM. Her federally-funded research focuses on the use of “digital health” to prevent injury and co-morbid risky behaviors among ED patients (and disseminating these strategies to ED clinicians). She teaches and mentors on a local and national level in both the EM and public health spheres. She is also an editor for Annals of Emergency Medicine.
- Dr. Heather Murray (@HeatherM211) is an emergency physician and award-winning medical educator at Queen’s University. She is an Associate Professor in the Department of Emergency Medicine and is cross-appointed to the Department of Public Health Sciences. She teaches diagnostic reasoning, evidence-based medicine and research skills to undergraduate medical students and emergency medicine residents at Queen’s.
On July 4, 2014 the Expert Responses and Curated Community Commentary for the Case of the Justified Junior was posted. You may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on July 4. That said, we’d love to hear form you, so please comment below!
All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.