When your attending is wrong...

[Ride a Bike]

Just wondering what people do when they are signing out with an attending and he/she makes a diagnosis that you think is incorrect. It doesn't seem like a good idea to go behind someone's back and take a case to another attending for review, but depending on the situation, it may change clinical management, etc. Any thoughts?

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[djmd]

Just wondering what people do when they are signing out with an attending and he/she makes a diagnosis that you think is incorrect. It doesn't seem like a good idea to go behind someone's back and take a case to another attending for review, but depending on the situation, it may change clinical management, etc. Any thoughts?

If you really think this I would not recommend going behind their back if you can avoid it...

Ask (or make a statement) about the alternate dx in signout...
Why isn't this __?

See if they will let you order immunostains....

And consider the possibility that they really are right..

And if it really makes a clinical difference..

 

[MOHS_01]

This should not be all that difficult of a situation.... either ask "why is this not____" or "I would have missed that. I thought it was _______".

Mistakes can & unfortunately do happen.

 

[mrp]

I would love it if a resident were to point out a mistaken dx that I was about sign. This would deserve special praise in their evaluation.

I would much rather be embarrassed in front of a resident, than sign an incorrect report and have to amend it...

 

[Master Chief]

When I was signing out with the OP the other day......

Funny, but this situation also happened to me a couple of times during my training, where I was the resident that thought the attending was wrong. The number of times I was actually right = zero. But it is never wrong to ask politely, "why wasn't it X instead of Y?" After all, you are in a training program and want to learn how to differentiate X from Y, so it is a natural question to ask. Also, there is the possibility that you are right and by asking an innocent question, both learned something and helped with that particular patient's care.

Can you be a little more specific to that the differential in this particular case? Perhaps it is something that does come up on occassion and we could discuss the pitfalls, etc.

 

[Ride a Bike]

The attending had already signed out the case. She brought it in to me because she thought I would find it interesting.

It was a microcystic tumor in the body of the pancreas (another resident grossed it in). Elderly patient. The tumor had been found incidentally. To my eyes it was a serous cystadenoma on the H&E. No question...
However, the surgeon had asked my attending to order IHC's because they were suspicious for a pancreatic endocrine tumor. The stains came back and were interpreted as positive for gastrin, glucagon, and somatostatin. The case was signed out as a pancreatic endocrine tumor. When I looked over the stains, I noticed that not just the cells of interest were staining, but so were fibroblasts, endothelial cells, actually just about everything. And when compared to the islet cells in the tissue that could be used as an internal control for the various antibodies, the staining characteristics were very different. I interpreted the stains as a false positive.

I told my attending all of this. I also ordered a PAS, which was positive.
The diagnosis remains unchanged.

 

[yaah]

Hmmm, well, I don't know what I would do in that situation if I was pretty sure they were wrong but they didn't listen to me. Generally, as people said, you can bring it up to the attending. DO NOT go behind their back. That is a quick way to lose a lot of respect.

A case like this, management might change since the endocrine tumor is potentially metastatic. But if you have already brought up your objections and nothing has happened, I don't know what else you can do. In truth, it isn't your responsibility, although I agree that it could be significant and they should at least show it around. The fact that the attending hasn't gotten the hint to at least show it around is a little irritating though.

I had a case recently that we got on frozen, was an abdominal nodule in someone undergoing I think a TAH for endometrial CA. It was fat necrosis, but areas kind of looked glandular on the frozen, so attending wanted to call it met adenoCA. I made my opinion that I favored fat necrosis and listed reasons why. Attending then asked me to show it to someone else, who agreed with me. At our place, most attendings will say that if you disagree with them, they are fine with you getting another opinion from someone else, but you have to tell the original attending first and clear it. I have never had an objection to that.

 

[yaah]

FYI, a story I heard about from years past in our program. We had a fellow who would take it upon himself to send out cases for an outside consult WITHOUT telling the attending who signed it out. That went over well.

 

[Gene_]

Another point not yet made is that stains never trump histology. Those two entities should look quite different on H&E. What about the more general NE stains? What did they show?

 

[dermpathdoc]

I would love it if a resident were to point out a mistaken dx that I was about sign. This would deserve special praise in their evaluation.

I would much rather be embarrassed in front of a resident, than sign an incorrect report and have to amend it...

Oh I sooo agree with this....I prefer to have the give and take from a resident who ison the balll and thinking of alternatives...
We all have our blind spots...

 

[tardieu]

The attending had already signed out the case. She brought it in to me because she thought I would find it interesting.

It was a microcystic tumor in the body of the pancreas (another resident grossed it in). Elderly patient. The tumor had been found incidentally. To my eyes it was a serous cystadenoma on the H&E. No question...
However, the surgeon had asked my attending to order IHC’s because they were suspicious for a pancreatic endocrine tumor. The stains came back and were interpreted as positive for gastrin, glucagon, and somatostatin. The case was signed out as a pancreatic endocrine tumor. When I looked over the stains, I noticed that not just the cells of interest were staining, but so were fibroblasts, endothelial cells, actually just about everything. And when compared to the islet cells in the tissue that could be used as an internal control for the various antibodies, the staining characteristics were very different. I interpreted the stains as a false positive.

I told my attending all of this. I also ordered a PAS, which was positive.
The diagnosis remains unchanged.

It sounds like you've duly considered and investigated the possibility that your attending may be right and you wrong, and have still come to the conclusion that you are right. It also sounds like you have tried to alert your attending of that, and the attending still does not agree.

Do you still believe you are right?

If yes, then you are obligated to take it another step.

As physicians, our first obligation is to our patients - not to our attendings, not to ourselves. If you really think you are right, and you have good evidence to support your position, you owe it to your patient to stick your neck out. Just imagine if it were your grandma, your child, or you, who would be subjected to a mistaken diagnosis and inappropriate treatment.

That said, you don't need to make a federal case out of it. My advice would be to gather all your slides, formulate your story and opinion and be ready to summarize it succinctly, then take it all to a senior pathologist or attending ally and state your case.

It will be awkward and difficult. But, if you really think you are correct, you have no choice.

I wish you well.

 

[DrBloodmoney]

The real question is 'Why isn't that case going for QC?'

 

[yaah]

It sounds like you've duly considered and investigated the possibility that your attending may be right and you wrong, and have still come to the conclusion that you are right. It also sounds like you have tried to alert your attending of that, and the attending still does not agree.

Do you still believe you are right?

If yes, then you are obligated to take it another step.

As physicians, our first obligation is to our patients - not to our attendings, not to ourselves. If you really think you are right, and you have good evidence to support your position, you owe it to your patient to stick your neck out. Just imagine if it were your grandma, your child, or you, who would be subjected to a mistaken diagnosis and inappropriate treatment.

That said, you don't need to make a federal case out of it. My advice would be to gather all your slides, formulate your story and opinion and be ready to summarize it succinctly, then take it all to a senior pathologist or attending ally and state your case.

It will be awkward and difficult. But, if you really think you are correct, you have no choice.

I wish you well.

I would modify this by asking the original attending if he/she would mind if you showed it to someone else, to get their opinion on it because it's a challenging case and you want to learn something about the differential.

 

[michaelrack]

.

As physicians, our first obligation is to our patients - not to our attendings, not to ourselves. If you really think you are right, and you have good evidence to support your position, you owe it to your patient to stick your neck out. .

I don't think it was the OP's patient. I believe his attending was showing him a specimen from another resident's patient.

 

[Ride a Bike]

True, this was not my case... but it doesn't matter. I knew from the beginning that I was going to have to show the case to another attending because this error has clinical importance. Thanks to all for the input. It was interesting to read what others might do in a similar situation. Let's hope it all ends up well.