on call woes-need advice

[Legion560]

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Hey all, Ive gotten myself in a sticky situation and need some advice. When our residency program takes call, typically the junior residents have a backup -or a senior resident (a third year overseeing everything) who typically guides decision making. The last call night, I had a patient come in as a consult to our service. I called the senior immediatly and told her about the situation, lab values, exam etc. She gave a a diagnosis and a plan which I followed. The attending staff on for that weekend was also notified and agreed with the senior's assessment and plan. Come monday during report, I present the patient to the other attending staff and get roasted and destroyed for an incorrect diagnosis and plan. The staff who was notified over the weekend even disagreed with what I presented. Now Im in a heap of trouble and may even get a formal reprimand.
(nothing happened to the patient by the way).
My argument is that I utilized the proper channels for supervision provided by the program. Namely, I told the senior-she formulated a diagnosis and plan-the attending was notified and now I am being hung out to dry for what THEY told me to do. How do I approach this? Especially is the senior decides not to go to bat for me?

 

[medicinesux]

sounds like you were thrown in front of the bus....welcome to medicine my friend.

 

[RTrain]

Hey all, Ive gotten myself in a sticky situation and need some advice. When our residency program takes call, typically the junior residents have a backup -or a senior resident (a third year overseeing everything) who typically guides decision making. The last call night, I had a patient come in as a consult to our service. I called the senior immediatly and told her about the situation, lab values, exam etc. She gave a a diagnosis and a plan which I followed. The attending staff on for that weekend was also notified and agreed with the senior's assessment and plan. Come monday during report, I present the patient to the other attending staff and get roasted and destroyed for an incorrect diagnosis and plan. The staff who was notified over the weekend even disagreed with what I presented. Now Im in a heap of trouble and may even get a formal reprimand.
(nothing happened to the patient by the way).
My argument is that I utilized the proper channels for supervision provided by the program. Namely, I told the senior-she formulated a diagnosis and plan-the attending was notified and now I am being hung out to dry for what THEY told me to do. How do I approach this? Especially is the senior decides not to go to bat for me?

Did the senior resident write a note? If not, did you document in your consult note, "Discussed with attending Dr. So-and-so who agrees with this plan"? Always load the boat - so when it sinks, you don't go under alone.

That said, it sounds like you're getting hosed, but I can't figure out why. It is standard procedure to discuss your plan with the senior resident, right? That's the way the system works? Which you did. So unless the senior is actively lying and saying that you didn't discuss with her, the assumption by the higher-ups will be that both of you were in agreement about the plan.

I wouldn't really worry too much about it. It probably seems like you're in more trouble to you than you really are. We all make decisions when on call that end up getting changed when the attending comes in the next day, and no matter how annoyed they act about it, all is forgotten 20 minutes later when everyone has moved on to the next activity.

 

[maceo]

give us info about the clinical situation so we can make a decision from the info.

 

[tripleJ]

Correction- you were thrown "under" the bus. Yeah- that's par for the course for intern year. You'll grow thicker skin. To quote Obama: use it as a "teaching example". Perhaps a beer summit is in order.

 

[Winged Scapula]

Unfortunately, this can be a common occurence. Your senior resident SHOULD have stuck up for you; after all, you ran the plan by her, she agreed and if it didn't work, it was her fault. She may not have even called the weekend attending to run the plan by him/her.

However, there are a lot of cowards in medicine who will not admit when they are wrong or made a mistake. As an intern, you pay for it but remember this as a lesson and to treat your interns well. When they fail, its a reflection on you and your teaching.

Your resident failed you by not admitting she was wrong (if the plan was indeed wrong) and had guided you incorrectly.

 

[TheAce]

As a chief last year, I would have stood up for the intern/junior and thrown the attending under the bus for not owning up to it. However, if the senior didn't call the attending on call and the patient went down hill or you went down the wrong diagnostic path, the senior should have taken the brunt of it and admittted the failure.

But keep in mind, if you are a troubled intern and don't understand the hierarchy, no one will stand up for you.

 

[Top Gun]

Did you document that you spoke with the senior and the attending? That should offer you some protection from the blame. The esenior/attending should have taken his/her share of the blame because they are responsible for supervising you, at least in theory. But in reality, there are some seniors who are cowards and will never admit that they made a mistake.

Unfortunately, there are many times when an intern will get blamed unfairly. When I was an intern, on rounds, the attending would, for example, complain to me about why I admitted a patient. Well, I didn't decide to admit the patient! That was the third year who made that decision after discussing the case with the ER physician. In our program, the third-year resident is responsible for screening patients for admission. I only came down to do the H&P after the patient had already been admitted. So you see, unfortunately sometimes the intern is a convenient whipping boy/girl.

 

[roja]

Make sure you document on every note that the plan was discussed with your senior resident, etc. its a sad state that we live in, but documentation is key in ALL issues.

Discuss this with your program director. Do not place blame, simply ask how YOU could have handled the situation better. The point is not to shift blame but to figure out how you can handle it when attendings change thier minds. (this will make you appear more mature and self directed in your learning, etc)

although it is a small consolation, you are a jr resident. you are supposed to make mistakes. My personal philosophy is that residents do not make mistakes, attendings do. Ultimately, residents are IN TRAINING. If an attending chooses to take the word of thier senior or fails to accept responsibility, it is thier fault.

 

[Legion560]

Well, its been a week and a half now and this thing hopefully has boiled over and has been deleted from memory banks. I went back and looked at my dicatation and sure enough, I documented that I talked to the senior. I think the reason this didnt go any further was because the staff probably saw the dictation later and decided not to pursue this. Nothing happened to the patient-discharged from the hospital in stable condition. Next time, Im going to go further and say "Discussed with Dr so-and-so who reviewed the labs and directed course of care" instead of just saying "spoke with senior". Overkill? Perhaps, but I cant think of a better way to go about it.

 

[Gastrapathy]

A good skill in roundsmanship is to make it clear that you discussed the case without making it seem like you are passing blame. So, the key to that is to make it part of the initial presentation when you think you might get fried.

ie "Dr. Cowardlyseniorresident and I talked about a lasix drip but we felt that the elevated BNP was related more to CKD than HF. So, we held off and planned to reassess in the am."

If everyone knows the players involved, just using "we" instead of "I" can serve the same purpose.

The key is to learn the nonverbal cues from an attending that is starting to get pissed and adapt the presentation on the fly. If you sense that they are unhappy, ensure that your assessment includes a broader differential with a plan to adapt interventions based on the w/u.

For a patient admitted over the weekend that is now being presented on a Monday, you should already know the quality/accuracy of your initial assessment and be ready to defend it.

Finally, your 'senior gave you a plan' is weak. Did you agree with the plan? Was the plan wrong because the data you gave your senior was wrong?

 

[Legion560]

Finally, your 'senior gave you a plan' is weak. Did you agree with the plan? Was the plan wrong because the data you gave your senior was wrong?[/QUOTE]

The information that was given was correct. The senior examined the patient herself and reviewed the information herself therefore ample opportunity existed for a change of plans and diagnosis. Since the senior had seen more of this clinical entity, they provided what at the time seemed life a reasonable plan and diagnosis. Perhaps I was wrong to assume that a senior level resident has a fund of knowledge and clinical aptitude that is sufficent to deal with these patients. So, put yourself in the shoes of a junior resident who is presented with a seemingly reasonable diagnosis and plan by your senior who has seen a lot more than you. Can you honestly say that when you were a junior resident you didnt rely on your superiors for guidance when something confused you? ?

BTW, I did my homework before presenting-looked up recent journal articles etc. The senior's diagnosis and plan agreed with what I read, except that the staff had other ideas. I did not sell out the senior during my presentation therefore "the senior gave me a plan" statement was not mentioned at any time. My point is that when you operate on a chain of command principle, the guy barking the orders from the top takes full responsibility for the guy at the bottom carrying out said orders. So "my senior gave me a plan" may be weak, but letting the junior get roasted for a plan the senior devised is much weaker-hell it isnt even in the same ballpark.

 

[Miami_med]

As an intern, your inherint position is being responsible for the implementation of other people's plans and intentions. There are many times where your plan is the one in play, but these are only the times where someone above you agrees and lets you take it beyond the first few steps which you might make before discussing it. You will probably be blamed by your attendings for the decisions of your seniors. You will be blamed by the floor staff for the decisions of your attendings. You will probably be blamed by the patients when anyone senior to you contradicts what you told them. It's just what happens. It's unfortunate. It's only a year long.

 

[Gastrapathy]

So "my senior gave me a plan" may be weak, but letting the junior get roasted for a plan the senior devised is much weaker-hell it isnt even in the same ballpark.

Yup. But from what you described, that resident wasn't even there to step up so what do you think should have happened?

 

[Law2Doc]

Yup. But from what you described, that resident wasn't even there to step up so what do you think should have happened?

90% of seniors are good and will step up to bat for their juniors. 10% out there will never go to bat for you. Interns learn who these 10% are fairly quickly (word of mouth spreads quickly), and defend themselves by either documenting things better or simply bypassing them and speaking to other seniors or even attendings wherever possible. The tendencies of these 10% frequently become known to the chiefs/attendings during the course of the year, because they are not insulated from the buzz/gossip that works its way through any small community of residents, and at least some have found it damaging to their careers. This is a culture of owning up to things and protecting your underlings from the attendings. Basically a two team game the residents vs the attendings -- the people who get things done and the people who spout out the plans. The system works best when the resident team has a unified front -- here's what we did and why. And the seniors have to back up the plan even if it's not the one they'd like it to be, in retrospect.

 

[Ypo.]

This same thing happened to me on my second night on medicine call. Unfortunately for the patient; he is not OK, but will hopefully get off the ventilator soon. My worries were not backed up by my senior resident; I presented the senior's plan to the attending who gave no additional suggestions. I pushed to call the intensivist, who did back up my thinking, but we should have consulted earlier. In the morning, I was chastised by the attending (the same attending I called twice about this patient) because I 'should have known not to admit this patient.' Success has many fathers, but failure is an orphan. 😀

In the end, I just learned from it what I could; to be more assertive and persistent when I'm not comfortable with a plan or think a patient's welfare is in danger. Of course, it's hard as an intern...

 

[dragonfly99]

Tough position...I've been in this position as an intern and also as a resident when a fellow did not own up to direction, or lack thereof, that she provided. To the OP - if the patient is OK and you didn't get any type of formal reprimand or letter in your file, or a major tongue lashing from the program director or others, I would let it drop. Nothing to be gained by pursuing this and you likely won't have to be supervised by that particular resident and attending much longer, unless you're in a small program or something. The good thing about IM is that most programs are pretty big...you end up being able to try and avoid some of the people you don't work well with, at least when you are PGY2/3.

I agree with gastrapathy about the presenting thing, though.

And you were smart to document that you discussed stuff w/the senior resident.