MD & DO Am I supposed to lie to my patients to appease my residents?

[Mecidimes]

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I'm a third year medical student currently on peds wards, and I have an issue with the residents that I'd like to ask you all about.

We have a very inquisitive, kind, and intelligent (not belligerent) family who is always asking us about our management of a patient with a very rare autoimmune condition. These people are professors at a local university, but have very little medical knowledge. Nonetheless, they want to know everything there is to know about the condition their child has because they want to manage it appropriately when they go home from the hospital. On the second day of admission, an ultrasound showed a hyperechoic liver, which was listed as abnormal by the radiologist and further clinical investigation was recommended. The family asked me for the results from this test, and what specifically it showed.

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

So, I left the room and went back to the resident workroom, where the intern asked me what I learned. I told them that the patient was fine for now, and that we talked about the labs that were ordered. The intern replied "What did you tell them?" And I told the whole story.

We then rounded, and in the patients' room the family had their usual number of (respectful) questions about plans, how their child got the disease, what could be expected in the future, and finally a single question about the abdominal ultrasound. One resident said "It was totally normal." Later in the discussion, a senior resident said that the liver was bright due to inflammation. The family accepted that response and was fine with the plan. (Like I said, this family is actually really good. Just very inquisitive.)

Well, after rounds, the same resident that said the test was "normal" then talked to us about "knowing exactly what we're going to tell the patient before we walk in the room so we don't look like we don't know what we're talking about." That resident spoke along the same lines multiple times for the remainder of that patient's stay, as did the intern.

I knew they were talking about my actions, but for the life of me I couldn't get a straight answer out of them as to what exactly they wanted me to do. What should I tell an inquisitive family? Should I lie? Deflect? Honestly the thought crossed my mind that maybe I should just make a habit of not looking at the lab results before I go in to see the patient so that I can honestly say I don't know, but then how exactly am I being "that patient's doctor" as my attending so earnestly tells me I should be?

(And I can't forget that these residents are evaluating me. Their perspective on my performance carries a great deal of weight when it comes to my clerkship grade, dean's letter, and most importantly matching into my chosen specialty.)

TL;DR How do I be a doctor to my patients while not pissing off the residents above me by telling patients more than the residents feel they need to know

 

[Save a life]

From what I understand, you never want to lie or withhold information from a patient or family. When you have results that are uncertain, that’s what you tell them and reassure them that you don’t know yet and you’ll need to do more tests.

Hiding or withholding information sounds like paternalism to me and my school has taught us over and over not to do that.

 

[sliceofbread136]

No you don’t lie. Your intern is wrong for saying that it is normal. If there is a finding that you think is incidental you mention it and explain why you aren’t concerned

 

[acapnial]

I'm a third year medical student currently on peds wards, and I have an issue with the residents that I'd like to ask you all about.

We have a very inquisitive, kind, and intelligent (not belligerent) family who is always asking us about our management of a patient with a very rare autoimmune condition. These people are professors at a local university, but have very little medical knowledge. Nonetheless, they want to know everything there is to know about the condition their child has because they want to manage it appropriately when they go home from the hospital. On the second day of admission, an ultrasound showed a hyperechoic liver, which was listed as abnormal by the radiologist and further clinical investigation was recommended. The family asked me for the results from this test, and what specifically it showed.

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

So, I left the room and went back to the resident workroom, where the intern asked me what I learned. I told them that the patient was fine for now, and that we talked about the labs that were ordered. The intern immediately replied "What did you tell them?" And I told the whole story.

We then rounded, and in the patients' room the family had their usual number of (respectful) questions about plans, how their child got the disease, what could be expected in the future, and finally a single question about the abdominal ultrasound. One resident said "It was totally normal." Later in the discussion, a senior resident said that the liver was bright due to inflammation. The family accepted that response and was fine with the plan. (Like I said, this family is actually really good. Just very inquisitive.)

Well, after rounds, the same resident that said the test was "normal" then talked to us about "knowing exactly what we're going to tell the patient before we walk in the room so we don't look like we don't know what we're talking about." That resident spoke along the same lines multiple times for the remainder of that patient's stay, as did the intern.

I knew they were talking about me, but for the life of me I couldn't get a straight answer out of them as to what exactly they wanted me to do. What should I tell an inquisitive family? Should I lie? Deflect? Honestly the thought crossed my mind that maybe I should just make a habit of not looking at the lab results before I go in to see the patient so that I can honestly say I don't know, but then how exactly am I being "that patient's doctor" as my attending so earnestly tells me I should be?

TL;DR How do I be a doctor to my patients while not pissing off the residents above me by telling patients more than the residents feel they need to know

It sounds like the residents were sending mixed messages, are you sure they were talking about you? The main problem I see in this story is that one resident said the result was normal and the other said it was abnormal.

The way you framed the results was fine. It's always ok to qualify that sort of thing with saying you need to do further testing/discuss with the rest of the team/discuss with the subspecialist before you can tell them what the results mean for sure.

Also make sure the patient knows you're a medical student.

 

[Redpancreas]

I'm a third year medical student currently on peds wards, and I have an issue with the residents that I'd like to ask you all about.

We have a very inquisitive, kind, and intelligent (not belligerent) family who is always asking us about our management of a patient with a very rare autoimmune condition. These people are professors at a local university, but have very little medical knowledge. Nonetheless, they want to know everything there is to know about the condition their child has because they want to manage it appropriately when they go home from the hospital. On the second day of admission, an ultrasound showed a hyperechoic liver, which was listed as abnormal by the radiologist and further clinical investigation was recommended. The family asked me for the results from this test, and what specifically it showed.

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

So, I left the room and went back to the resident workroom, where the intern asked me what I learned. I told them that the patient was fine for now, and that we talked about the labs that were ordered. The intern replied "What did you tell them?" And I told the whole story.

We then rounded, and in the patients' room the family had their usual number of (respectful) questions about plans, how their child got the disease, what could be expected in the future, and finally a single question about the abdominal ultrasound. One resident said "It was totally normal." Later in the discussion, a senior resident said that the liver was bright due to inflammation. The family accepted that response and was fine with the plan. (Like I said, this family is actually really good. Just very inquisitive.)

Well, after rounds, the same resident that said the test was "normal" then talked to us about "knowing exactly what we're going to tell the patient before we walk in the room so we don't look like we don't know what we're talking about." That resident spoke along the same lines multiple times for the remainder of that patient's stay, as did the intern.

I knew they were talking about my actions, but for the life of me I couldn't get a straight answer out of them as to what exactly they wanted me to do. What should I tell an inquisitive family? Should I lie? Deflect? Honestly the thought crossed my mind that maybe I should just make a habit of not looking at the lab results before I go in to see the patient so that I can honestly say I don't know, but then how exactly am I being "that patient's doctor" as my attending so earnestly tells me I should be?

(And I can't forget that these residents are evaluating me. Their perspective on my performance carries a great deal of weight when it comes to my clerkship grade, dean's letter, and most importantly matching into my chosen specialty.)

TL;DR How do I be a doctor to my patients while not pissing off the residents above me by telling patients more than the residents feel they need to know

You plead incompetence. Obviously you shouldn’t always be doing this, but when you truly don’t know, you don’t know. This is basically what you did and you did nothing wrong and are blaming yourself. Sounds like the resident’s trying to mark his or her territory.

@sliceofbread136 : I didn’t know you were a Peds resident dude. I thought you were IM. You’re one of my favorite SDN posters lol.

 

[LilKangaroo]

My 0.02, you're overanalyzing this (coming from someone who overanalyzes everything).

It sounds like the resident who said that the ultrasound was normal was embarrassed from being corrected by the senior resident as inflammation is not normal. It's likely this resident was trying to cover their own mistake and was not talking about you at all.

From the perspective of a resident, we don't pay that much attention to the medical students' conversations with families and we certainly don't hold it against you if you explain something wrong or not in the best way. The patient is going to expect the more experienced member of the team is correct and whatever you said is water under the bridge. Keep being enthusiastic, engaged, and good team member and you'll be fine.

Also, grades don't matter.

And don't lie to the patients - if you don't know what something means on a result just be honest and say what you saw, you don't know what it means, and assure your patient that the residents will explain it later.

 

[Crayola227]

It's very easy to dodge this, and quite appropriate for you to do so.

"Since I am a medical student, it would be best for everyone to wait for your treating physician to discuss the results with you." If you are pushed as to why and if you've seen the results. "I have seen the results, but since I am not your treating physician, I can't interpret them for you."

"Can't you just tell me what it says?"

"I'm not qualified to interpret these results, and every test must be correctly interpreted in its full clinical context to have meaning. I must confer with my supervising physicians first. I'm sorry."

"Then what good are you, medical student?"

"I have quite a bit more time than the treating physicians to gather information from everyone involved, patients, labs, doctors, in order to facilitate communication and get things done."

It's very clear in this case that not only you, but the residents as well, did not have consensus on what the results actually meant.

Remember the concept of do no harm. You don't help patients by parroting back lab results without the appropriate clinical context or interpretation. This is why some labs/clinics have a policy that positive HIV results not be given over the phone. The list goes on and on examples where harm is done when patients are given a bit of data they have no ability to put into context, and left to run with it.

You don't have to lie, but you have to sack up and be willing to not only ACCEPT your limitations, but INFORM patients about them. It can be hard as a student when you feel useless to have to say so to patients, but get used to doing it now, because it becomes crucial once you're a physician trainee.

 

[SouthernSurgeon]

As the student on the team? You aren’t the doctor yet so your TLDR is kind of missing the point.

You should very rarely be the first person discussing new test results and significant findings with the patient, especially if it’s a family where communications have been challenging for whatever reason.

And if you are the first person delivering that information it should be because you and your team have talked about it first and they are comfortable with you doing so and/or have set expectations/boundaries/limits about what and how to discuss.

As to how to answer the family in the moment? There’s about a million ways to do it but a simple - “oh Dr Smith really wanted to discuss those findings with you and will be in shortly” works perfectly well.

 

[DrSnips]

You should very rarely be the first person discussing new test results and significant findings with the patient, especially if it’s a family where communications have been challenging for whatever reason

This entirely. While it would be lying to say that you don't know the test result, it is not lying to say you don't know what the test result means. Because the meaning of the result is the obvious next question after learning the result, you should really defer this question to the residents / attending, as there is likely to be much more discussion beyond revealing the result.

 

[AlmadeDr]

Phrasing and team consensus is important. Most times I've been involved in a situation where we have had to manage angry family members or do damage control has been as a result of the patient or family's perception that they are getting different stories or conflicting information from the various team members. And people can often take what we say out of context; if a result is not presented with a reasonable theory and well formed plan, out comes Google once you're out of the room telling them 50 catastrophic things it could be.

Now, it doesn't necessarily sound like your residents are all that adept at handling this fine line either, as they were not on the same page about when the information was going to be given to the family. I can't tell from your story whether it is just general discomfort with the process or maybe unwritten policy (like wanting to wait for the attending, from what I've heard some peds programs are like this)

As a student, you are unfortunately going to be placed in this situation many times. The natural schedule of any teaching hospital is such that patients see the student/intern first, then are seen/managed by the senior resident, then finally attending shows up later. Plans may change at any of these points and make what you've said sound inconsistent with the rest of your team. If you check in with your team (prior to seeing the patient) about what the family should know now or ask them when you can tell the family to expect new information, they will appreciate it (both family and residents, lol). Several people have provided good hedging phrases above if you are not sure and need to check first.

For what it is worth, as a senior IM resident, I will allow students to participate in the process of sharing results and new plans. I do pre-coach them, however, so I know they fully understand the plan themselves and that they are using appropriate layperson English. And I'm typically in the background of the room when they do so I can jump in if there is a question or something else that rattles them and provide further clarification.

Sent from my Pixel XL using Tapatalk

 

[Doctor-S]

Phrasing and team consensus is important. Most times I've been involved in a situation where we have had to manage angry family members or do damage control has been as a result of the patient or family's perception that they are getting different stories or conflicting information from the various team members. And people can often take what we say out of context; if a result is not presented with a reasonable theory and well formed plan, out comes Google once you're out of the room telling them 50 catastrophic things it could be.

As a student, you are unfortunately going to be placed in this situation many times. The natural schedule of any teaching hospital is such that patients see the student/intern first, then are seen/managed by the senior resident, then finally attending shows up later. Plans may change at any of these points and make what you've said sound inconsistent with the rest of your team. If you check in with your team (prior to seeing the patient) about what the family should know now or ask them when you can tell the family to expect new information, they will appreciate it (both family and residents, lol). Several people have provided good hedging phrases above if you are not sure and need to check first.

This ... agree.

 

[VincentAdultman]

OP you don't go over new lab/study results without the OK of your team and even then you need to go over how you present them.

 

[Newyawk]

It's very easy to dodge this, and quite appropriate for you to do so.

"Since I am a medical student, it would be best for everyone to wait for your treating physician to discuss the results with you." If you are pushed as to why and if you've seen the results. "I have seen the results, but since I am not your treating physician, I can't interpret them for you."

"Can't you just tell me what it says?"

"I'm not qualified to interpret these results, and every test must be correctly interpreted in its full clinical context to have meaning. I must confer with my supervising physicians first. I'm sorry."

"Then what good are you, medical student?"

"I have quite a bit more time than the treating physicians to gather information from everyone involved, patients, labs, doctors, in order to facilitate communication and get things done."

It's very clear in this case that not only you, but the residents as well, did not have consensus on what the results actually meant.

Remember the concept of do no harm. You don't help patients by parroting back lab results without the appropriate clinical context or interpretation. This is why some labs/clinics have a policy that positive HIV results not be given over the phone. The list goes on and on examples where harm is done when patients are given a bit of data they have no ability to put into context, and left to run with it.

You don't have to lie, but you have to sack up and be willing to not only ACCEPT your limitations, but INFORM patients about them. It can be hard as a student when you feel useless to have to say so to patients, but get used to doing it now, because it becomes crucial once you're a physician trainee.

I need to memorize these lines before i start rounds. The problem is nobody makes you feel like an idiot during preclinical years so many students feel like they know so much when in reality the practice is very different. Ie ive built an arrogance that i know will hurt me if i dont actively fight it. So thanks for this

 

[Ismet]

How do I be a doctor to my patients while not pissing off the residents above me by telling patients more than the residents feel they need to know

You missed the point.

It's not a matter of what "the residents feel they need to know." There's a time and a way to discuss results, especially in pediatrics with results that may be ambiguous but may also mean scary stuff to the parents. It's really not the med student's place to discuss potentially serious results with a family unless you've discussed it and gotten the go-ahead from your resident.

 

[AMEHigh]

Yikes.

We always make it clear to our students that they shouldn't discuss results with patients. A simple "Dr. X will be in shortly to disscuss with you" will suffice.

Also, even if results have been discussed with a patient and they are asking questions about prognosis, treatment, etc for serious conditions, please do the same thing and tell them "I'll ask Dr. X to come speak with you."

Patients are already confused enough with nurses, PAs, other specialists giving them information, it does not need to be made worse by students giving incorrect information. You may not realize it, but us residents (and attendings) are typically 10 steps ahead of you (might've already talked to a specialist, might've already ordered follow up blood work, etc), so don't complicate matters by giving out incorrect information unless directly told to do so by your team.

 

[prettylittlebird]

Yikes.

We always make it clear to our students that they shouldn't discuss results with patients. A simple "Dr. X will be in shortly to disscuss with you" will suffice.

Also, even if results have been discussed with a patient and they are asking questions about prognosis, treatment, etc for serious conditions, please do the same thing and tell them "I'll ask Dr. X to come speak with you."

Patients are already confused enough with nurses, PAs, other specialists giving them information, it does not need to be made worse by students giving incorrect information. You may not realize it, but us residents (and attendings) are typically 10 steps ahead of you (might've already talked to a specialist, might've already ordered follow up blood work, etc), so don't complicate matters by giving out incorrect information unless directly told to do so by your team.

I definitely agree with this - students shouldn't be the first ones to discuss results. We've been told it is acceptable to tell a patient that a test is back and that their primary physician will come in to talk with them about what that means. This doesn't mean that the students don't sometimes explain the results of a test or lab because often we do but it's in the context of having spoken about it with at least the resident and having a plan of action ready to give to the family/patient. I do think sometimes students will see results back before interns or residents simply because we have less to do overall (less patients, paperwork etc.) and then it's fine to bring it up with the resident. This is just my experience however and the residents I worked closely with were always appreciative when I knew the most recent information because occasionally it was something they hadn't had a chance to check and it saved them time. Experiences on this will vary so just make sure you know the preferences of your team because you don't want to annoy anyone by constantly asking them if they know about XYZ and what they're going to do about it.

 

[Tenk]

As a student, you should not be interpreting diagnostic results on your own and reporting these findings to the family unless you have a 100% understanding of what you are saying or you have a senior backup with you in case you get overwhelmed. Even telling someone “you have appendicitis” you may come under a barrage of questions you had no idea could even be asked. I know I have. It’s clear from your post that you didn’t understand the US report whereas I could probably look at it for 10 seconds and tell you exactly what to tell the family so you had some ammo going in. There’s nothing wrong with you not knowing how to frame things at your stage of the game. There is something wrong with you trying to frame things without any backup.

Overall, just be more careful in the future especially with families you know are quite inquisitive. Don’t beat yourself up either. You did nothing wrong but doing what you did can get you into trouble albeit rarely.

 

[sliceofbread136]

Yikes.

We always make it clear to our students that they shouldn't discuss results with patients. A simple "Dr. X will be in shortly to disscuss with you" will suffice.

Also, even if results have been discussed with a patient and they are asking questions about prognosis, treatment, etc for serious conditions, please do the same thing and tell them "I'll ask Dr. X to come speak with you."

Patients are already confused enough with nurses, PAs, other specialists giving them information, it does not need to be made worse by students giving incorrect information. You may not realize it, but us residents (and attendings) are typically 10 steps ahead of you (might've already talked to a specialist, might've already ordered follow up blood work, etc), so don't complicate matters by giving out incorrect information unless directly told to do so by your team.

Not trying to be inflammatory here but this honestly makes me think you aren’t creating a good environment for your students to learn. Not only does it sound like you don’t keep them in the loop very well, you are expressly forbidding them to share any information? Sounds like a great way to make an intern who not only doesn’t know what he is doing but doesn’t know how to communicate with parents either

 

[AMEHigh]

Not trying to be inflammatory here but this honestly makes me think you aren’t creating a good environment for your students to learn. Not only does it sound like you don’t keep them in the loop very well, you are expressly forbidding them to share any information? Sounds like a great way to make an intern who not only doesn’t know what he is doing but doesn’t know how to communicate with parents either

You really want a med student telling you that you have cancer or HIV or that there is potentially something wrong on their imaging study? I'm sorry but being a student they are there to learn and we help facilitate that but my job is patient care first and foremost.

 

[DocWinter]

A MS3 should not be the 1st line contact for receiving and interpreting results.

If in that position, simply state you are not fully comfortable or capable of giving them the best information and the (resident, attending) will be in shortly.

 

[emergentmd]

I'm a third year medical student currently on peds wards, and I have an issue with the residents that I'd like to ask you all about.

We have a very inquisitive, kind, and intelligent (not belligerent) family who is always asking us about our management of a patient with a very rare autoimmune condition. These people are professors at a local university, but have very little medical knowledge. Nonetheless, they want to know everything there is to know about the condition their child has because they want to manage it appropriately when they go home from the hospital. On the second day of admission, an ultrasound showed a hyperechoic liver, which was listed as abnormal by the radiologist and further clinical investigation was recommended. The family asked me for the results from this test, and what specifically it showed.

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

So, I left the room and went back to the resident workroom, where the intern asked me what I learned. I told them that the patient was fine for now, and that we talked about the labs that were ordered. The intern replied "What did you tell them?" And I told the whole story.

We then rounded, and in the patients' room the family had their usual number of (respectful) questions about plans, how their child got the disease, what could be expected in the future, and finally a single question about the abdominal ultrasound. One resident said "It was totally normal." Later in the discussion, a senior resident said that the liver was bright due to inflammation. The family accepted that response and was fine with the plan. (Like I said, this family is actually really good. Just very inquisitive.)

Well, after rounds, the same resident that said the test was "normal" then talked to us about "knowing exactly what we're going to tell the patient before we walk in the room so we don't look like we don't know what we're talking about." That resident spoke along the same lines multiple times for the remainder of that patient's stay, as did the intern.

I knew they were talking about my actions, but for the life of me I couldn't get a straight answer out of them as to what exactly they wanted me to do. What should I tell an inquisitive family? Should I lie? Deflect? Honestly the thought crossed my mind that maybe I should just make a habit of not looking at the lab results before I go in to see the patient so that I can honestly say I don't know, but then how exactly am I being "that patient's doctor" as my attending so earnestly tells me I should be?

(And I can't forget that these residents are evaluating me. Their perspective on my performance carries a great deal of weight when it comes to my clerkship grade, dean's letter, and most importantly matching into my chosen specialty.)

TL;DR How do I be a doctor to my patients while not pissing off the residents above me by telling patients more than the residents feel they need to know

I tell this to all Med students, residents, nurses when patients asks about lab results or direction of care. If you are going to tell the patients test results, you better be ready to answer all of their questions about care correctly, which as a med student you have no clue about 90% of the time.

As medical students, your job is to be a sponge and not to make care decisions. Pts thinks med students have a great deal of knowledge which you really don't so they will ask complicated/specific questions. The last thing I want to do when I walk into the room is a stressed out family firing off questions on abnormal lab results when many times abnormal lab results are not pertinent.

No one is asking you to lie, but really you should never give our any results.

Even if its a no brainer and a CT shows a large malignant tumor. It does no one any good telling patients this unless you are prepared to answer all of their questions which you are not.

 

[VincentAdultman]

Not trying to be inflammatory here but this honestly makes me think you aren’t creating a good environment for your students to learn. Not only does it sound like you don’t keep them in the loop very well, you are expressly forbidding them to share any information? Sounds like a great way to make an intern who not only doesn’t know what he is doing but doesn’t know how to communicate with parents either

If a student did that on my service I would be....less than pleased.

I understand that students have to learn sometime, but taking it upon oneself to talk to families is not the way to go. The student should talk with their resident/attending about the findings, if it's appropriate to communicate the results to family, how the information should be presented and what questions to anticipate.

But med students should not be making the decision unilaterally to talk to patients and their families about results.

 

[operaman]

I see two issues OP:

1) You overstepped your role slightly, even with the best of intentions. That's ok, we've all done it in one way or another. Just be mindful and have strategies for next time. I especially liked SouthernSurgeon's very simple "yeah, Dr. Smith wants to go over those with you personally and will be in soon." This won't end by the way -- this happens to residents too. Even happens to attendings ("hey doc, now that we've talked about my sinuses, can you see if my spine MRI is back yet? What's it say?"). You will face this again and find a new way to screw it up. Welcome to the club.

2) At least one of your peds residents is an a--hat. Hopefully the senior or attending had a private conversation with them later, but only a weak resident trying to compensate for poor clinical and time management skills would blurt out a blatantly false answer like that. The biggest lesson is not to become one of these residents 18 months from now when you're no longer a student. Hopefully over your clinical years you will work with some truly good residents so you have some ideas of how to be a good one yourself.

My experience is that residents like you mention tend to practice "call room medicine" and spend most of their time doing paperwork and farting around. They also don't have a great grasp of disease processes and the overall arc of clinical care so they struggle to keep track of what's being done and what needs to happen next. It's really easy to get pinned to the EMR as a resident and you have to actively fight it. If I had a nickel for every time as a consulting surgical service we've rounded on a consult patient in some sort of acute distress and the only people in the room are bedside nurses and maybe, if we're lucky, an NP. No primary team MD anywhere to be found. "We paged them 30 minutes ago..."

As for what to tell patients and when, I admit this is something I wrestle with on a personal level. It should absolutely never be a student put in that awful position of giving results to families. As a resident, I have frequently found myself, especially at night on call, in the position of having to give people some pretty terrible news. I do feel like you should only give news you can field questions about because these will inevitably follow, but I've also seen patients transferred in from outside hospitals where between that facility and ours they've spoken to 5 or 6 physicians before I get there and not one has told them they probably have cancer. I've settled on the idea that if I know or highly suspect something like cancer, I will be the one to tell them immediately. Sometimes this is for malignancies that are non-surgical and for which I don't really know the ins and outs of treatment, but I feel like it's better for the patient to hear it first from someone they know already before the oncology consult team shows up. I've found that telling people earlier allows them extra time to rally their support systems, get family to bedside, and get past the initial shock so they can have a meaningful conversation with the next team. Sorry if that's a bit off topic.

OP, as for evals, I think if you just keep on performing well you should be fine. My guess is the resident involved in far more personally embarrassed by it than anything -- I know I would be if I blurted out inaccurate info in front of my whole team.

 

[Crayola227]

it's a skill to learn how to "dodge" and "hedge" - the polite term is "managing expectations"

being a doc is a little bit of being a gambler

Listen to what the "Gambler" told Kenny Rogers

"Son, I've made a life
Out of readin' people's faces
And knowin' what the cards were
By the way they held their eyes....

You got to know when to hold 'em,
Know when to fold 'em,
Know when to walk away,
And know when to run.
You never count your money
When you're sittin' at the table.
There'll be time enough for countin'
When the dealing's done.

Every gambler knows
That the secret to survivin'
Is knowin' what to throw away
And knowin' what to keep.
'Cause every hand's a winner,
And every hand's a loser,
And the best that you can hope for
Is to die in your sleep."

 

[Keona]

What I was taught as a medical student was that if a test comes back that may be critical to patient care or that seems slightly abnormal was to think of it as not having ownership of the test and to just say that you really don't understand it and have to talk with the residents about it, sometimes saying that you have no idea what this test is supposed to say so you can't say if it's abnormal or not. Confusing and scaring a family is something you absolutely don't want to do so we would discuss it as a team and then if it was my medical student patient I would go back with a resident member of the team, or sometimes attending and resident to explain the test results thoroughly. At some point the questions asked would be something I couldn't answer and the resident or attending would take over. The more sensitive the matter the less of the team present.

What I would often tell the patient is we are still waiting on more information and as soon as we know enough to put it together we will come back and explain it in detail. As a resident I will still do this, I do not want a medical student ever telling a patient their HIV test is positive by themselves, this is because I want to be able to be there with the patient and offer support and make sure they don't feel suicidal after hearing the results, not because I don't think the medical student is capable of explaining the test results to the patient.

The other thing to remember is most of the patients may consider you as the medical student their doctor, you are able to spend a longer period of time with them, you giving them conflicting information from the resident breaks some of the trust. I never lie to patients, I am a horrible liar and they would immediately be able to tell, but I also don't think it's ethical to lie. In the case of the family you are discussing I would probably offer to show them the results on the computer as the resident and have said we are still learning everything going on in your child's unique case and we are going to be here to help while we are figuring everything out.

 

[docsmom1]

I have been on this site over the years as my son went through med school interviews, the match, matching, and now getting ready to finish his 3rd year of residency in a few months. Occasionally, I read varied threads. I can tell you, that one of the things I did when my Father was seriously ill, was I told him, "Long coats - doctors, short coats - students". He knew who to talk to because he had me. Most patients don't know this distinction. They see a white coat, and they are going to ask. Take heart from the suggestions here. They are good ones. You've just done what you are supposed to do - learn. This is a valuable experience which will help you greatly when it is your turn to be the resident. You will know how to educate the patient, and the student, to "do no harm".

 

[Snoopy2006]

A general point: one of the worst things a medical student can do is overstep his/her boundaries when it comes to medical discussions with patients. Too often a medical student lacks the context to fully interpret biopsy/imaging results and discuss their implications with patients. The most unpopular students we've had would try to counsel patients (incorrectly) on their diagnoses and prognoses before the resident or attending entered the room. It was a lot of work for us to undo the anxiety that those students had caused by the time we saw the patients.

I'm not saying that's the scenario in the OP's post, I only skimmed it. But a general rule for medical students is to be careful with your medical discussions. When a patient asked me for results as an M3, a simple answer was, "I'm still in training and learning, but I'll be back soon with Dr. *** and the whole team, and we'll be able to discuss those results and answer any questions you have then." It's best to be open and clear with your residents/attendings about expectations beforehand.

 

[Psai]

I have been on this site over the years as my son went through med school interviews, the match, matching, and now getting ready to finish his 3rd year of residency in a few months. Occasionally, I read varied threads. I can tell you, that one of the things I did when my Father was seriously ill, was I told him, "Long coats - doctors, short coats - students". He knew who to talk to because he had me. Most patients don't know this distinction. They see a white coat, and they are going to ask. Take heart from the suggestions here. They are good ones. You've just done what you are supposed to do - learn. This is a valuable experience which will help you greatly when it is your turn to be the resident. You will know how to educate the patient, and the student, to "do no harm".

Pretty much every school except medical school gives out long white coats to their students including physical therapy assistants, dieticians, nurses.

 

[Anti-PD1]

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

That's your mistake. 10/10 times in your shoes I would have said "I'm not sure, I'll ask the team, and we'll visit you soon to share the results." The only time I've shared results with the patient is when I've discussed them with the residents and have been explicitly told I can. I.e. you have a subdural, that means xyz... Now if the patient has a further question after that, I defer to the residents again and relay the question to the team when I get back.

You aren't managing this patient. You are helping in every other way, and learning. The line can be difficult to see, but err on the side of caution.

 

[arcus]

Thing is, I had nowhere to hide; no smoke and mirrors to throw up. I couldn't say "I don't know" because I *did* know; I looked at the report just a few minutes ago. I couldn't say "It was normal" because it wasn't normal. So, I told them that the ultrasound showed a brighter-than-normal liver, and we weren't sure what that meant just yet in his care. I alleviated their concerns by saying it could be a variant of normal, but we'd know more when more tests came back. They were fine with that. (Really, they were.)

Humility is your friend. Relish now as a medical student to act dumb, tell everybody you do not know, and that you will ask a doctor when a patient wants an opinion

very soon you will be the bearer of bad news as a real physician and you will wish you could say, “let me find someone who knows”.

If humility isnt your thing, think of liability. That latter will have you wishing you had said nada

 

[hmockingbird]

Yeah I agree with the general consensus. The intern should not have said it was normal when it wasn’t (ok... unless it’s something like an incidental finding that’s a normal variant and the family isn’t into details; since you were working the patient up more based on the results it doesn’t sound like that’s the case here). I think what you said is fine but next time I would go over results with the team first. (As a student I often gave non-critical results to patients and families so this may be school/hospital dependent.) However sometimes it’s appropriate to defer to the residents or attendings. For example as a med student I walked into an exam room and the parents asked me if their kid’s CF result was back yet. I did not have the training/experience to deliver that news if it was positive and I knew the attending would prefer to be in the room (if not giving the news themselves). I told them I didn’t know when in truth I knew it was back and I could have looked it up that moment. My attending told me I did the right thing. Then he looked it up and told the family. Sometimes in my residency we have a result but time to plan for a way to best deliver that result to a family. Again if it’s not an excessive wait time (you don’t want the family to wait long for an important result obviously) having that small amount of time to prep (whether I’m giving the news myself or calling a fellow/attending to give the news, depends on the specialty) can help things go more smoothly. I would say in general responding how you did +\- something about discussing further with the doctors is probably fine (better if you’ve discussed the plan already with the team). If it’s a really big result like a new cancer diagnosis I would ask your residents how/if you (personally) should discuss with the patient/family.