dealing with mistakes as a resident

[zoondel]

Hi all,
After a rough night in the ICU last week (nobody died, but it was scary), I was wondering how well other residents deal with the mistakes we make along the way. I'm not talking about the extremes - i.e. second-guessing everything when a patient dies, or a chief chewing you out for forgetting to fill out a medication reconciliation form - but the errors in clinical judgment that we need to learn from.

It think it would be helpful to all of us - I would certainly appreciate it - if we could share some brief stories about the difficult cases: a missed diagnosis, delay in blood work, not giving the ancillary staff enough credit.

Also relevant would be situations where, as residents, an attending says one thing, and even though we might disagree, our hands/brains are tied.

Looking forward to hearing and sharing.

Thanks.

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[a winner is you]

Easy, I don't make mistakes.

(sarcasm, obviously, but just in case)

 

[koennen]

Looking forward to hearing and sharing.

Well, since you started the thread, why don't you start by sharing your mistake(s).

 

[Buzz Me]

An actual mistake, or a complication (big difference)?

 

[confuse]

From a medical student's perspective, alot of the resident's "mistakes" comes from the break down in communication and the failure to take full advantage of their staff (nurses, med students, etc.). As a med student, there have been a few occasions that I have presented important info during rounds that caught the residents off guard. Then, instead of trying to work on better communication with me, the natural reaction of most of these residents was to blame it on me for making looking bad because I didn't track them down to tell them about these salients info. Yet, they never bothered to read the long note that I put in the chart nor responded to my page.

 

[Law2Doc]

From a medical student's perspective, alot of the resident's "mistakes" comes from the break down in communication and the failure to take full advantage of their staff (nurses, med students, etc.). As a med student, there have been a few occasions that I have presented important info during rounds that caught the residents off guard. Then, instead of trying to work on better communication with me, the natural reaction of most of these residents was to blame it on me for making looking bad because I didn't track them down to tell them about these salients info. Yet, they never bothered to read the long note that I put in the chart nor responded to my page.

You were way way way out of line here. Basically broke the unwritten code/ violated the culture. As a med student, your job is to help the residents, not sandbag them. You really should never put yourself into a position where you go over their head and present new info directly to the attending that conflicts with what the resident is saying. You instead talk to the resident first, let them know what you are going to say. This is going to hold true when you are an intern too and your chief presents something you disagree with. This is a team approach, with residents being your senior teammates, and you aren't a team player if you take the legs out of under a teammate. You will understand a lot better when you get further along and realize that many residents do a lot to protect the med students, interns, etc only to get burned by folks who simply don't know their role on the team. It's not their job to better communicate with the dude that makes them look bad in rounds, except to tell him to stop doing it as it's inappropriate.

At any rate this has nothing to do with resident mistakes, this is a med student blunder for sandbagging his resident.

 

[mpdoc2]

From a medical student's perspective, alot of the resident's "mistakes" comes from the break down in communication and the failure to take full advantage of their staff (nurses, med students, etc.). As a med student, there have been a few occasions that I have presented important info during rounds that caught the residents off guard. Then, instead of trying to work on better communication with me, the natural reaction of most of these residents was to blame it on me for making looking bad because I didn't track them down to tell them about these salients info. Yet, they never bothered to read the long note that I put in the chart nor responded to my page.

Prepare for shi.tty evaluations and a shi.tty residency program. By doing what you're doing your essentially killing your chances...

 

[confuse]

Once again, so typical reflex reaction from a resident. FYI, the intern who signed off on my note is fully aware of the info and also assumed that the resident (who were on call overnight) was already aware of this info as well. This is not an issue of med student going over the resident's head. It should be approached as a communication break down that needs to be better facilitated between the team members. It is easy to blame the med student but instead of addresing the med student, how about perhaps showing up for pre-round or asnwering to your pages?!

 

[Law2Doc]

Once again, so typical reflex reaction from a resident. FYI, the intern who signed off on my note is fully aware of the info and also assumed that the resident (who were on call overnight) was already aware of this info as well. This is not an issue of med student going over the resident's head. It should be approached as a communication break down that needs to be better facilitated between the team members. It is easy to blame the med student but instead of addresing the med student, how about perhaps showing up for pre-round or asnwering to your pages?!

I'm sure there are plenty of things any resident could do better from a med students' perspective, and that's not really relevant here. However making ones-self available to the med students is not usually high on a resident's priority list. You should have pulled him aside a minute before rounds when you saw him, not openly conflicted him just because he didn't communicate with you well enough. Honestly, when I've seen med students do what you are describing, they tend to get negative resident comments and often get sent to do unsavory tasks. The culture isn't going to change for you -- you need to get with the culture. And that's not to sandbag your residents. The same will hold true when you are an intern and a second year resident and so on. You protect the team. A unified front to the attendings. You can fight all you want on a one-on-one basis but once you go outside of that conversation, the senior's view is the one you don't contradict.

This isn't a kneejerk reaction at all, just a piece of advice. On rotations as a med student, your goal is first and foremost to get good evaluations. Virtually every attending is going to get resident feedback about med students. They really have no other basis for evaluating how that med student is in terms of being a team player etc. So your goal is the come off as a team player. You don't accomplish this by undermining the residents. You might feel like you are making a contribution to patient care by feeding info to the attending that the residents for whatever reason choose not to relate, or info that contradicts what they are saying. But it's still a bad idea. The attending won't remember it an hour later. The residents will. Which is why it benefits you to appreciate that the culture dictates that you talk to the residents directly, not sandbag them. A med student who debates a course of action with the resident but doesn't contradict the resident on rounds does infinitely better than one who throws his teammates under the bus. That's really all there is to it. They can always hurt you more.

 

[confuse]

Law2Doc,
I did not think to pull my resident aside (nor my intern) because we both assumed that the resident already knew since he/she was on call overnight. And it's not contradicting my resident because I was the one doing all of the presentation; the resident wasn't saying anything so there's nothing to contradict. I understand what you're saying but I don't think you understand my point. I'm done with all of my rotations for med school and have received good eval from that rotation, so I'm speaking in the spirit of someone who will start residency in a few months and trying to point out ways that myself and others can become a good resident/intern. I know the culture, but maybe the culture should change. One thing I noticed is that when something goes wrong, the attending always take full responsibility even if it's the resident or intern's fault. On the other hand, if something goes wrong and "looks bad" to the attending, many residents instead of taking full responsibility, start pointing fingers. So are we sacrificing patient care for the culture of trying to "look good" to our attendings?

 

[turquoiseblue]

Hi all,
After a rough night in the ICU last week (nobody died, but it was scary), I was wondering how well other residents deal with the mistakes we make along the way. I'm not talking about the extremes - i.e. second-guessing everything when a patient dies, or a chief chewing you out for forgetting to fill out a medication reconciliation form - but the errors in clinical judgment that we need to learn from.

It think it would be helpful to all of us - I would certainly appreciate it - if we could share some brief stories about the difficult cases: a missed diagnosis, delay in blood work, not giving the ancillary staff enough credit.

Also relevant would be situations where, as residents, an attending says one thing, and even though we might disagree, our hands/brains are tied.

Looking forward to hearing and sharing.

Thanks.

I don't know if you would consider this relevant, but was in a situation where there was an alzheimer's (AD) patient in the ICU who was in cardiac arrest..i was on call that night alone, so i called a code...resuscitation was successful. and suddenly a fellow told me that i should have let him die because he has AD and his quality of life isn't so good and said his wife is a looney bin and we shoudln't allow her to make decisions. but there was no DNR at the time, so i know i did the right thing. he was on my case nonetheless. after that the senior fellow made sure that the patient's guardians were the doctors and made him DNR. a few days later the pt coded again and we didn't resucitate. it was sad though, that guy's alzheimer's wasn't so progressed..he completely made sense and wasn't completely demented and i think he deserved a chance to live but there was nothing i could do about it. what if a cure for AD comes about? technology is getting better and better. i guess i didn't completely make a mistake here but still, you can see how someone can make a right thing into a wrong thing and try to make you look bad for trying to do the right thing just because they can.

 

[Pix87]

i guess i didn't completely make a mistake here but still, you can see how someone can make a right thing into a wrong thing and try to make you look bad for trying to do the right thing just because they can.

Oh woe is you, the world of medicine is out to get you! Can I offer you some Kleenex?

The ethical principle at issue here goes WELL beyond you or the fellow. Physicians have been grappling with the question of purpose in prolonging life for a LONG time with no clear/universal ethical standard or answer. Leave it to you to make a profound ethical dilemma your own little pity party. Pathetic.

Note to OP: A little humility goes a long way, especially when you make a mistake.

 

[Law2Doc]

Law2Doc,
I did not think to pull my resident aside (nor my intern) because we both assumed that the resident already knew since he/she was on call overnight. And it's not contradicting my resident because I was the one doing all of the presentation; the resident wasn't saying anything so there's nothing to contradict. I understand what you're saying but I don't think you understand my point. I'm done with all of my rotations for med school and have received good eval from that rotation, so I'm speaking in the spirit of someone who will start residency in a few months and trying to point out ways that myself and others can become a good resident/intern. I know the culture, but maybe the culture should change. One thing I noticed is that when something goes wrong, the attending always take full responsibility even if it's the resident or intern's fault. On the other hand, if something goes wrong and "looks bad" to the attending, many residents instead of taking full responsibility, start pointing fingers. So are we sacrificing patient care for the culture of trying to "look good" to our attendings?

Generally the culture is for the most senior person involved in the decision to eat the blame. That's true whether it's an attending or a resident or an intern. But even if that's not the way it works where you end up, you need to embrace whatever culture is there because a single intern isn't going to make a dent in a longstanding culture, and even if you plant the seeds to start changing culture, it's generally a very slow moving change and you will be long gone before you see any significant evidence of culture change. So don't kid yourself that you are going to change bad culture.

Your initial post described presenting info in rounds not once, but on multiple occasions, that caught the residents off guard. That's a problem, and it's not a problem because the resident didn't do a good job of seeking you out, but the other way round. You are blindsiding people. Not once but on multiple occasions by your own post. You aren't getting that part of your job is to make the team look like it's on the same page. I would thus regard the problem to be at the med student level, not the resident level in this scenario. Sorry if I'm not grasping the situation, but putting myself in the shoes of the resident here, show me up once, that's not cool and you will get a talking to. Show me up on multiple occasions and not only would I have something negative to say to you in evals, but there will be lots of rectal disimpactions in your future, even if I have to make a few phone calls to friends on other services to find some.

 

[liliequist]

a single intern isn't going to make a dent in a longstanding culture, and even if you plant the seeds to start changing culture, it's generally a very slow moving change and you will be long gone before you see any significant evidence of culture change. So don't kid yourself that you are going to change bad culture.

I'm not siding with either L2D or confuse but it's precisely this kind of attitude that perpetuates bad practice, whatever it is, and punishes those who try to do what they think is best for patient care even if it means stepping out of line. This is the 'hidden curriculum'; most people fall in line, put their head down and shrug their shoulders and say, 'well that's just the way it is'. I don't think applying that mentality to any situation is particularly intelligent. Maybe this is also why there are so few physicians involved in health care reform / legislation / policy. I mean, it's so much easier to just accept common practice, even though that practice may be deeply flawed, right?

 

[digfast]

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[Perrotfish]

I'm sure there are plenty of things any resident could do better from a med students' perspective, and that's not really relevant here. However making ones-self available to the med students is not usually high on a resident's priority list. You should have pulled him aside a minute before rounds when you saw him,

. On rotations as a med student, your goal is first and foremost to get good evaluations..

A senior resident is the primary teacher for medical students and they are, in fact, responsible for being available to medical students. The vast majority of residents I've had understood that and pre rounded with us in depth before the attendin arrived. As for the few that didn't most were rarely if ever surprised by one of my findings. For the few who are left: I'm sorry but if you're too overwhelmed/lazy/inefficent to discuss my patients AND you don't know what's going on with them then it's not my responsibility to hide your incompetence from your boss.

For that matter, how do I even know when to pull the resident aside? Other than running my entire list with the resident, how do I intuit which one of the labs or complaints in my note that the resident isn't aware of?

One thing I don't think you should do, ever, is let the attending miss out on vital information to save face for the resident. The patient comes first, even ahead of your evals.

 

[Law2Doc]

...
For that matter, how do I even know when to pull the resident aside? Other than running my entire list with the resident, how do I intuit which one of the labs or complaints in my note that the resident isn't aware of?...

If the incident had happened to the prior poster once, I would tend to agree with you. But he's contending that residents are being caught off guard by what he's presenting on multiple occasions, and that he'd already gotten chewed out over it and still somehow hit the same issue, and blames the residents for not keeping lines of communications open. In those specific circumstances, it's kind of hard to put the blame on the resident here.

I think you have to realize that while there is a teaching function asked of residents, it's definitely very secondary to the resident's actual duties at most programs. The intern or non-senior residents may be expected to "teach" the med students, but chasing them down before rounds isn't going to be a priority. If a med student has information that potentially could sandbag a resident, and he already has a track record of doing exactly that, it's the med student's job to make sure he doesn't do it again. It's common sense really. You don't make the same mistake twice.

 

[confuse]

Law2Doc,
You are jumping to conclusions too early. My post said that I have A FEW occasions, you translated to MULTIPLE occasions. The few occasions that I have had are all spread out through my medical school career, not all occurring during this specific rotation. Furthermore, I was only admonished once, meaning the other ones were insignificant. Anyway, you do not need to fight me because I'm not trying to be the defensive med student. I'm already moving on to the next stage of my career and since this topic is about how to be a better resident, I share my story with that thought in mind.

 

[Perrotfish]

If the incident had happened to the prior poster once, I would tend to agree with you. But he's contending that residents are being caught off guard by what he's presenting on multiple occasions, and that he'd already gotten chewed out over it and still somehow hit the same issue, and blames the residents for not keeping lines of communications open. In those specific circumstances, it's kind of hard to put the blame on the resident here.

I think you have to realize that while there is a teaching function asked of residents, it's definitely very secondary to the resident's actual duties at most programs. The intern or non-senior residents may be expected to "teach" the med students, but chasing them down before rounds isn't going to be a priority. If a med student has information that potentially could sandbag a resident, and he already has a track record of doing exactly that, it's the med student's job to make sure he doesn't do it again. It's common sense really. You don't make the same mistake twice.

1) Again, I disagree that 'chasing down' medical students before rounds isn't a major priority for the senior resident. I think a senior resident who doesn't preround is skipping out on of his biggest resonsibilities.

2) The OP said this only came up a couple of times, not over and over again. However if the medical students are consistently embarassing the residents by bringing up things that the resident didn't know about than I see that as a serious problem with the residency/program rather than with the medical students. My observation has been that residents and interns are usually pretty proud of a medical student that caught something they missed, because it's so rare that everyone sees it as a novelty. If its happening often enough that the resident thinks its threatening rather than praiseworthy I'd be concerned about that resident. If all the residents are like that I'd be worried about the program.

The lesson I'd take from this is, whatever your saw your senior residents doing as an Intern, when it's your turn to be a senior resident you need to take the time and initiative to preround with each medical student about each and every patient they're carrying. Otherwise it could be embarassing for everyone.

 

[Rendar5]

Perrot, just keep in mind that all hospitals run a bit differently and at different times of the year. One hospital where the senior resident may be directly in charge of taking care of med students, in another hospital, it may be more the intern who's the primary educator of the med students. I had both experiences during the course of my med school training.

Regardless, communication gaps take 2 people to make happen, and someone assuming that the other person should find them for something they consider important is just as culpable as the person without the extra information. saying "i put it in my note and they should read it" is the exact same thing. All things should at least be run by the senior resident before dealing with the attending because it's a good way to ensure that communication failures don't happen. And if the senior resident isn't doing enough to collect the info, the info needs to be given to him. His chief or the attending should be the one to correct his behavior, the med student and the intern on the other hand needs to deal with the system as best as possible.

 

[Rendar5]

Now to get back to the OP, I don't know who said it, prolly someone on one of hthese boards. a favorite quote of mine is that good judgment comes from experience, and experience comes from bad judgment.

When dealing with a medical mistake, be up front about it, be humble and accept the mistake, accept whatever humiliation comes your way and above all learn from it. Same thing goes for complications whether they're expected or not.

 

[Bostonredsox]

I'm going to have to agree with confuse here. I had many many occasions as a medical student, particularly as a third year when I pointed something out to my resident that was in my note because I assumed, and usually correctly, that they would not actually read my note, and they just flat out ignored me. Or they would say, thanks I'm aware of that already just stick to writing your notes and I'll handle my patients care. Then when I presented my info to the attending they would whisper to each other and bitch about me trying to make them look bad. I actually brought this up in private with an attending because it disturbed me. Bottom line is if you ignore your medical students and treat their opinons as worthless and don't pay attention when they gather and present information that is designed to make your job easier, you can't be pissed when they step over you. No one wants to be made to feel like their a fly on the wall. On top of that, it teaches them to act the same way when they become residents and the cycle continues. I'm very glad my program has 20-30 full time med students at it year round so I can work with them and ensure them that I value their opinon as only a very very short time ago I was in their shoes. Their jobs are not to make my day easier. Their job is to learn. If in doing so they help me out and make my day a bit easier thats awesome. But at the end of the day I'm the physician and I'm getting paid to care for patients. They are students who are paying tuition to learn.

 

[Law2Doc]

I'm going to have to agree with confuse here. I had many many occasions as a medical student, particularly as a third year when I pointed something out to my resident that was in my note because I assumed, and usually correctly, that they would not actually read my note, and they just flat out ignored me. Or they would say, thanks I'm aware of that already just stick to writing your notes and I'll handle my patients care. Then when I presented my info to the attending they would whisper to each other and bitch about me trying to make them look bad. I actually brought this up in private with an attending because it disturbed me. Bottom line is if you ignore your medical students and treat their opinons as worthless and don't pay attention when they gather and present information that is designed to make your job easier, you can't be pissed when they step over you. No one wants to be made to feel like their a fly on the wall. On top of that, it teaches them to act the same way when they become residents and the cycle continues. I'm very glad my program has 20-30 full time med students at it year round so I can work with them and ensure them that I value their opinon as only a very very short time ago I was in their shoes. Their jobs are not to make my day easier. Their job is to learn. If in doing so they help me out and make my day a bit easier thats awesome. But at the end of the day I'm the physician and I'm getting paid to care for patients. They are students who are paying tuition to learn.

While I don't disagree with the scenario as you've presented it, IMHO (a) most residents don't ignore their med students in the way you describe, and (b) med students don't always appreciate what is critical information the attending needs versus not. What I find problematic in the prior post however was the fact that this was happening with the same med student not once, but multiple times where his residents felt he was sandbagging them. When we are talking about multiple events with the only commonality being the med student, it's just easier for me to believe that the problem was less about the system or the residents. Anything's possible though.

 

[Bobblehead]

From a medical student's perspective, alot of the resident's "mistakes" comes from the break down in communication and the failure to take full advantage of their staff (nurses, med students, etc.). As a med student, there have been a few occasions that I have presented important info during rounds that caught the residents off guard. Then, instead of trying to work on better communication with me, the natural reaction of most of these residents was to blame it on me for making looking bad because I didn't track them down to tell them about these salients info. Yet, they never bothered to read the long note that I put in the chart nor responded to my page.

Please don't take this type of attitude with you through the rest of your career as it will become detrimental to your well-being. If you have important information, which you may or may not as a med student, but as you go up the "food chain" you likely will it is your job as a physician to inform the relevant parties, particularly when dealing with complex patients. Consultant/primary care physician didn't return your page? Call him back later, leave a message, etc. Part of being a physician is convincing others that something is important be that patients or other providers. If you're failing to do, you're failing at your job of communicating.

For your short-term well-being don't be known as the guy that sandbags people. Residency is worse than high school.