How to disagree with a resident

[dyk343]

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Being relatively new to externships I have run into several situations where I did not agree with the resident's diagnosis. I am sure we have all been there. So far I have been silent in all my endeavors because who am I to challenge a resident? Also, until today none of the things I disagree with have been serious. I'm certainly not going to express my opinion over a resident's if the difference of outcome is minimal. Plus differing opinions is a fantastic way to learn. Most of us will likely get to the same end point with a slightly different approach.

Well... Today there was a case where I simply 100% disagree with the diagnosis. I truly believe the resident was sloppy in his/her workup. The patient is going to have surgery over the issue, while I am certain it is unwarranted and will not fix the problem. It's pretty blatant that the diagnosis is wrong. I will not say specifics because I don't want to be identified.

How do you politely challenge a diagnosis? I know the typical response is "find the resident in the hall in an isolated/appropriate situation and talk about your thoughts" but in this case this was not feasible. The patient signed on the dotted line right in front of me and is off to surgery next week. Plus this is a very egotistical resident (we all know the type) where challenging would likely not go over too well.

I know I sound egotistical myself, but I can guarantee most of us would also disagree given the clinical scenario.

Should I just grow a pair? Turn a blind eye? Pick a paper during journal club that covers the topic? Hope the attending closely reads the charts and questions the diagnosis?

What would you/have you done in this situation?

 

[hematosis]

you can just throw in your differential dx and ask him why he is dismissing it. I know if a student corrected me i would be much impressed with his/her skills. However, if they did it in a nasty way...i'd probably make them clip toe nails for a wk.

 

[Traum]

Go to the attending, or chief of foot surgery, or the CMO. You have a fiduciary duty to the patient. It takes brass/moxy to do the right thing. It's easy to go with the flow, don't make the waves, do the PC thing, etc....However, that's why status low prevails.

IF this was your mom, what would you want someone to do?

Just b/c you're a student should not hinder your critical thinking. Everyone is a student, including attendings. Speak up. This is someone's loved one.

 

[ldsrmdude]

Being relatively new to externships I have run into several situations where I did not agree with the resident's diagnosis. I am sure we have all been there. So far I have been silent in all my endeavors because who am I to challenge a resident? Also, until today none of the things I disagree with have been serious. I'm certainly not going to express my opinion over a resident's if the difference of outcome is minimal. Plus differing opinions is a fantastic way to learn. Most of us will likely get to the same end point with a slightly different approach.

Well... Today there was a case where I simply 100% disagree with the diagnosis. I truly believe the resident was sloppy in his/her workup. The patient is going to have surgery over the issue, while I am certain it is unwarranted and will not fix the problem. It's pretty blatant that the diagnosis is wrong. I will not say specifics because I don't want to be identified.

How do you politely challenge a diagnosis? I know the typical response is "find the resident in the hall in an isolated/appropriate situation and talk about your thoughts" but in this case this was not feasible. The patient signed on the dotted line right in front of me and is off to surgery next week. Plus this is a very egotistical resident (we all know the type) where challenging would likely not go over too well.

I know I sound egotistical myself, but I can guarantee most of us would also disagree given the clinical scenario.

Should I just grow a pair? Turn a blind eye? Pick a paper during journal club that covers the topic? Hope the attending closely reads the charts and questions the diagnosis?

What would you/have you done in this situation?

If the attending is approachable, I would bring it up with him/her. Ultimately it is the attendings patient. If you don't feel comfortable talking to the attending, I would bring it up with the resident. One way would be to make it as a teaching moment for the resident. Maybe something like "I have a hard time understanding XXXXX. I know you diagnosed that in this patient yesterday. Could you tell me how you came to the diagnosis?" If he's arrogant, he'll probably love the opportunity to teach you. Either you'll understand what his thought process is and maybe end up agreeing with him (or at least not being 100% opposed) or you'll prove to yourself that he was sloppy and missed the diagnosis. If you still disagree with him, I would bring it up during the course of that conversation.

 

[dyk343]

The attending actually talked to the resident today to "clarify the note". I suspect the patient will be surprised next week.

I appreciate the replies. But given the situation, which is hard to relate in words.. I still do not see how I could have corrected the resident in a proper fashion in front of the patient. I was planning my comments today, and was going to bring it up with him/her but the attending did the dirty work for me.

I suppose it could have been a moment to shine, but it also could have gone south very quickly.

 

[dyk343]

.i'd probably make them clip toe nails for a wk.

You wouldn't do that anyways? Haha

 

[g squared 23]

I'll make a completely contrasting argument.

How is the best way to disagree with a resident? The best way is to NOT do it at all.

Worst case scenario, absolute worst case is that patient gets booked for the surgery and the attending is dumb enough to book it based on said resident's diagnosis. So what? It's not like this is going to significantly disrupt that patient's life RELATIVE to other much more serious and life altering surgeries. It's great that we take what we do so seriously, but being honest with ourselves, we get REALLY worked up over minor "complications" whereas other specialties "redo" much larger and significant surgeries all the time and call it normal progression of that disease process.

At the end of the day, it's JUST foot surgery; saying anything to the resident could possibly negatively affect your career and close doors for you professionally which honestly is more important than that patient's hammertoe. Of course we take the oath to do no harm, and we all want what is best for our patient's, but don't risk your future with tedious over-ethical paranoia, ESPECIALLY as a student who isn't actually involved in their surgical care.

Fire away.

 

[NatCh]

I'm curious, what was the Resident's diagnosis and what was your diagnosis?

 

[ldsrmdude]

I'll make a completely contrasting argument.

How is the best way to disagree with a resident? The best way is to NOT do it at all.

Worst case scenario, absolute worst case is that patient gets booked for the surgery and the attending is dumb enough to book it based on said resident's diagnosis. So what? It's not like this is going to significantly disrupt that patient's life RELATIVE to other much more serious and life altering surgeries. It's great that we take what we do so seriously, but being honest with ourselves, we get REALLY worked up over minor "complications" whereas other specialties "redo" much larger and significant surgeries all the time and call it normal progression of that disease process.

At the end of the day, it's JUST foot surgery; saying anything to the resident could possibly negatively affect your career and close doors for you professionally which honestly is more important than that patient's hammertoe. Of course we take the oath to do no harm, and we all want what is best for our patient's, but don't risk your future with tedious over-ethical paranoia, ESPECIALLY as a student who isn't actually involved in their surgical care.

Fire away.

I understand your point of view, but I disagree with it. If you as a student are positive the diagnosis is wrong and surgery is either unneeded or potentially harmful, then I don't think keeping quiet is the best choice. I think you're brushing off some potentially serious harm that could come from the surgery. It would be interesting to know what the procedure would have been (there's a difference between a hammertoe and a major reconstructive procedure in terms of complications, I agree). Are there times when keeping quiet might be the best course? Yep. But most of the time, I think saying something is the way to go. Again, just my opinion.

Just curious, g squared, how would you handle a student disagreeing with your diagnosis? I'd like to think I would be open about it, but (especially if I didn't like the student to begin with) I could see me not handling it well.

 

[Traum]

Keep quiet, or mum, is fine. That is the status quo/status low.

Your future is more impt than a patient, their family, or just a hammered toe-- (making $$$ and paying those massive student loans-unlike other countries whereby education is a human right and subsidized by rate payers). Money (future) and career (money) are very impt. to some.

Podiatry remains inbred, and everyone knows everyone, and profiteering from everyone. Well known.

Maybe, we can change that. With thinkers. People who Speak up. People who believe that patients deserve better than egos and political nonsense that has created a sinking ship country.

Enough of nonsense. IT is not just foot surgery--that bone and soft tissue is attached to a loved one. Or are you just a foot dentist playing into a hamster wheeling game of selling surgery? Do you want to be a sheeple, yes man, afraid, enslaved in that future, "career"/money, or take a higher road, and walk tall with integrity, and change that family tree of status low?

Did you not take an oath? ethics-are they impt, if so, when? We are ALL students, we all learn, and must think critically. The wallet is quite an attraction. We know, it's america, money trumps everything, and we must create, define, and sell those needs to keep our gas on, and food in that fundus.

"it's just foot surgery"--well, that may explain our lowly standing as ancillary service providers and fighting for parity as we delve into 2014 for more proclamations and "leaders" selling more false hopes.

In america, you have NO job security, it's dog eat dog, it's all about money, and then getting punched in the face with 40-50+% taxes for what exactly?. Period.

No more Horatio Alger nonsense, bootstrapping, and feel good hard worker stories.

When is it a duty to speak up on behalf of the patient, their family, for national care--that's something we must answer and sleep at night.

 

[dyk343]

For once, I actually agree with Traum.

As I said, I was preparing how to approach the resident. But the attending did the dirty work for me.

I do not want to be identified. Podiatry is small and who knows if the resident/attending are reading these forums? I probably have already revealed too much.

 

[HaimFeldman]

I'll make a completely contrasting argument.

How is the best way to disagree with a resident? The best way is to NOT do it at all.

Worst case scenario, absolute worst case is that patient gets booked for the surgery and the attending is dumb enough to book it based on said resident's diagnosis. So what? It's not like this is going to significantly disrupt that patient's life RELATIVE to other much more serious and life altering surgeries. It's great that we take what we do so seriously, but being honest with ourselves, we get REALLY worked up over minor "complications" whereas other specialties "redo" much larger and significant surgeries all the time and call it normal progression of that disease process.

At the end of the day, it's JUST foot surgery; saying anything to the resident could possibly negatively affect your career and close doors for you professionally which honestly is more important than that patient's hammertoe. Of course we take the oath to do no harm, and we all want what is best for our patient's, but don't risk your future with tedious over-ethical paranoia, ESPECIALLY as a student who isn't actually involved in their surgical care.

Fire away.

And if said patient dies on the operating table from an adverse reaction to anesthesia from an unnecessary operation? Or if they develop a raging staph infection and lose a toe? What then? It's no long a minor complication, is it? These instances are rare, but it has happened.

 

[jq225]

Keep quiet, or mum, is fine. That is the status quo/status low.

Your future is more impt than a patient, their family, or just a hammered toe-- (making $$$ and paying those massive student loans-unlike other countries whereby education is a human right and subsidized by rate payers). Money (future) and career (money) are very impt. to some.

Podiatry remains inbred, and everyone knows everyone, and profiteering from everyone. Well known.

Maybe, we can change that. With thinkers. People who Speak up. People who believe that patients deserve better than egos and political nonsense that has created a sinking ship country.

Enough of nonsense. IT is not just foot surgery--that bone and soft tissue is attached to a loved one. Or are you just a foot dentist playing into a hamster wheeling game of selling surgery? Do you want to be a sheeple, yes man, afraid, enslaved in that future, "career"/money, or take a higher road, and walk tall with integrity, and change that family tree of status low?

Did you not take an oath? ethics-are they impt, if so, when? We are ALL students, we all learn, and must think critically. The wallet is quite an attraction. We know, it's america, money trumps everything, and we must create, define, and sell those needs to keep our gas on, and food in that fundus.

"it's just foot surgery"--well, that may explain our lowly standing as ancillary service providers and fighting for parity as we delve into 2014 for more proclamations and "leaders" selling more false hopes.

In america, you have NO job security, it's dog eat dog, it's all about money, and then getting punched in the face with 40-50+% taxes for what exactly?. Period.

No more Horatio Alger nonsense, bootstrapping, and feel good hard worker stories.

When is it a duty to speak up on behalf of the patient, their family, for national care--that's something we must answer and sleep at night.

Nicely stated.

 

[NatCh]

.............

 

[g squared 23]

To ldsrmdude:
Yeah, a student questioning me would be incredibly annoying, and I would like them even less if they were already on my bad side. However, a tactful student making it an academic discussion who is nonconfrontational would be welcomed. The problem is (from my experience), most students are NOT tactful, are often annoying and come off as insubordinate and rude and would not be able to tactfully pull off such a maneuver. And from my experience, questioning a resident's judgement is about the most insulting thing a student can do, whether the student is correct or not.

And let me tell you, a resident liking you a lot will never guarantee you get a spot at a program, but a resident HATING you CAN guarantee that you do NOT get that program. This point is really where my advice to students comes from. Yes we all want to do best for all our patients, but enter at your own risk, and if you slip up, it can cost you dearly in your professional life. And my point again: is saving that hammertoe really worth pissing off that resident (or attending)? That is for you students to decide for yourselves, and that is my point which has been lost amongst all of the idealistic saints that grace these forums.

 

[NatCh]

G squared 23 brings up a good point. Tact is a skill that one needs to practice. I promise you guys that people disagreeing with you and contradicting your opinion will continue for the rest of your careers, and learning how to deal with it tactfully is something you will need to be able to do.

 

[g squared 23]

G squared 23 brings up a good point. Tact is a skill that one needs to practice. I promise you guys that people disagreeing with you and contradicting your opinion will continue for the rest of your careers, and learning how to deal with it tactfully is something you will need to be able to do.

Thank you Dr. Nat, and to illustrate the point, let's present a situation that we will all encounter at some point in our careers: the nonoptimal surgical result.

You will have your postops show up in other colleagues' offices and vice versa, and some of these cases and results will NOT be perfect or to the patient's liking. Assume that patient needs revisional surgery. Practitioners without any tact may end up throwing their colleague under the bus (even accidentally) to make themselves look good, and if that patient sues that other doctor, your name WILL come up. That doctor and others in the area will find out and most likely not be very happy, and any time they see one of your bad results they will speak poorly of you as well.

However, the tactful physician can set these patients' minds at ease, shift the focus from the poor result to the future treatment plan, and even offer the patient revisional surgery ALL without making their colleague out to be the bad guy. Bumbling blowhards on the other hand can encourage the spark that can set a lawsuit fully ablaze.

 

[NatCh]

I think dyk343 did alright with this one. He knew enough to not just go blurting something out that cause an awkward situation.

 

[GSRaw]

How do you politely challenge a diagnosis?

You don't "challenge" anything, you're a student...You give a differential if you're asked to do so, otherwise you live and learn. It's not the end of the world for the patient, but it will be for your chances if you piss off the resident just to be "right." Soon, you will have new students thinking they know more than you staring you in the face.