In a Hospital Hierarchy, Speaking Up Is Hard to Do

By BARRON H. LERNER, M.D.
13 july 2008--The patient needed a spinal tap, and a senior attending physician asked a medical resident whether a preparatory blood test had been checked. The medical student who told me this story was stunned to hear him answer in the affirmative, because she was quite certain it had not been checked.
Well, almost certain.
Doctors in training sometimes confront situations in which they worry that their supervising physicians are making mistakes or bending the truth. Yet even though such acts can jeopardize patients, the inclination and ability of young doctors to speak up is hampered by the hierarchies in teaching hospitals.
Modern medical education can be traced to a series of reforms that began in the late 19th century. One of the most notable occurred at the Johns Hopkins University School of Medicine, where educators initiated a formal system to train students on the clinical wards.
At the same time, professors at Johns Hopkins and elsewhere instituted early versions of modern residency training programs, in which residents — newly minted doctors — learned their profession on the wards from attending physicians and, in turn, taught students.
This new division of labor established hierarchies. On the top were the senior physicians who made rounds on the wards once or twice daily. Next were the overworked residents, who essentially lived in the hospital while training. Last were the medical students, who spent the most time with patients but were most assuredly at the bottom of the heap.
Although some senior physicians welcomed feedback from their juniors, others disdained it, either overtly or through intimidation. And students were all too easily intimidated. In a 1993 article in The New England Journal of Medicine, a Harvard medical student reported that although her resident routinely made derisive remarks about her patients on rounds, the rest of the team laughed nervously rather than confront her.
Similarly, as Dr. Adam J. Wolfberg wrote in the same journal last month, for years medical students performed pelvic examinations on anesthetized women who had not given consent because senior obstetricians said it was the best way to learn internal anatomy. Although this practice made many students uncomfortable, most were afraid to speak up.
The student whose resident seemingly lied to the attending physician about the blood test did not speak up either. The resident was a good doctor, she said, and so she had given him the benefit of the doubt. And, she added sheepishly, both the resident and the attending physician would be grading her.
Even when students do speak up, they may be ignored. A student recently told me he had examined a patient and concluded that she might have a severe abdominal disorder. But when he told the resident, who had seen the patient earlier and more quickly, the resident refused to re-examine the patient. He then reminded the student that while he had examined hundreds of such cases, the student had seen only a few. The student admitted that he was far from positive that something was seriously wrong.
What should a medical student do in such a situation? One possibility is to take the matter up with a more senior doctor. Or the student might go directly to the patient or family, telling them that the physicians have a genuine disagreement and that they deserve to know about it.
These options seem eminently logical on paper. After all, in each of these examples, patients are at risk of harm, something that physicians must avoid at all costs. As the ethicist James Dwyer has written in The Hastings Center Report, “The practice of always keeping quiet is a failure of caring.” But in the real world, it may be extremely difficult to go up the chain of command.
Fortunately, medical educators are increasingly recognizing the dilemmas that doctors in training confront when they witness behavior that makes them uncomfortable. Students and residents are now expected to provide routine feedback — positive and negative — about their supervising physicians at the close of their rotation.
Of course, as Dr. Penny Henderson and her colleagues at the University of Cambridge wrote in 2005, physicians and students need to be educated about how to give feedback in professional and nonconfrontational ways. Medical educators are only now beginning to teach this skill.
Still, it will be hard to change the unfortunate perception that constructive feedback, even for a patient’s benefit, is whistle-blowing.