Should I let attendings know about this resident's behavior?

[badskittles]

Hi SDN forums,

Hope you all are enjoying yourselves- I am questioning if I should report an intern that had some major shortcomings as I felt patient care was compromised. While I sympathize the learning process, I felt that there were dangers to the patients that perhaps the attendings should be aware of. I will name the resident "Alex". We saw multiple patients in *half* a day, and there were red flags in each of the visits.

1st visit. Spanish speaking patient had a virtual translator in the room. In the beginning of the visit, she nodded as if she comprehended what Alex was saying to her in English. Alex proceeded to tell the translator "just translate the parts that need to be translated". However, how can the translator know what needs to be translated?!? Alex decided to go through lab results purely in English, but patient showed confusion on her face and Alex continued to not use the translator. Additionally, when the physical exam was conducted, the patient could not follow any simple commands including "pull or push"

2nd visit. patient came in with symptoms of receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god. This patient had also previously seen a psychiatrist and was taking anti-psychotic which the patient stopped themselves. However, when I presented the patient to Alex, the resident simply dismissed it as a mental illness that all religious people suffer from. I was supposed to present on the patient to the attending, but instead decided to present themselves, because he wanted to "not make it sound like the patient was having delusions". However, when we reviewed the chart further, apparently Alex had seen the patient and was told the patient had a schizophrenic disorder. When Alex presented to the attending, they flipped the script entirely and talked about the delusions.

3rd patient. pregnant mother at 39w0d, G1P0000 was scheduled for induction next week to which she was very nervous about the induction and was wondering if she could wait a few days past the due date for chance natural birth despite being against medical advice. However, Alex kept misinterpreting the question and repeatedly said that induction takes a while and so the birth might happen perhaps 12-24 hrs past the due date, and that the mother needs to stick with the induction date. Alex , at one point, snapped at the mother. Alex did not offer shared decision making and the family was visibly upset and frustrated with Alex

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[SpoiledMilk]

First I commend you for recognizing in what can go wrong in practice from what you have learned theoretically in the classroom. Learn from it and make sure when you are practicing, don 't do what the intern is doing.

I'm guessing that you are a MS3 or MS4? I would highly recommend that unless you witness said intern do something so egregious like ordering the wrong medication that would harm or kill the patient, physically assault the patient, etc., to keep your nose down and not make any waves. It's hard for me to advise this because I have also witness things during clerkships that I thought about reporting but did not because of unspoken retaliation. And it does happen.

If the upper residents or attendings do not already know of the intern's transgressions, eventually they will find out and will/should act accordingly. You as the MS3/4 just continue to act professionally and keep your nose clean. The rest of your time in medschool will be less stressful for it.

 

[Lawpy]

First I commend you for recognizing in what can go wrong in practice from what you have learned theoretically in the classroom. Learn from it and make sure when you are practicing, don 't do what the intern is doing.

I'm guessing that you are a MS3 or MS4? I would highly recommend that unless you witness said intern do something so egregious like ordering the wrong medication that would harm or kill the patient, physically assault the patient, etc., to keep your nose down and not make any waves. It's hard for me to advise this because I have also witness things during clerkships that I thought about reporting but did not because of unspoken retaliation. And it does happen.

If the upper residents or attendings do not already know of the intern's transgressions, eventually they will find out and will/should act accordingly. You as the MS3/4 just continue to act professionally and keep your nose clean. The rest of your time in medschool will be less stressful for it.

What about anonymously reporting bad residents?

 

[SpoiledMilk]

There are avenues for anonymously reporting bad resident behavior, and OP can go that route. However, advice from my senior medstudents dissuaded me from even reporting such incidents anonymously when I observed them because of the subjective nature of said incidents.

 

[Candidate2017]

It all sounds subjective from your part but no real patient danger even if assuming everything you stated is 100% correct. It will likely be just a he said/she said between you and the intern. I wouldn't expect a med student to know safe/not safe. I wouldn't trust an intern either, but at least interns have senior residents to provide a layer of supervision as well.

But report if you do feel patient safety is affected. Though I don't feel like it's warranted. Wait till you're an intern and you'll know why med students are the bane of an intern's existence. Or you could be one of those interns who lecture at med students for hours.

 

[GoSpursGo]

I more or less echo what others have said. There is a difference between being truly unsafe, and just not being very good. It sounds like the latter. But in general, if an intern is subpar the attendings probably know about it. I would advise you to focus on learning what you can from the rotation, do your best, and unless there's a real patient safety issue let the attendings come to their own conclusions about the resident.

 

[xffan624]

Hi SDN forums,

Hope you all are enjoying yourselves- I am questioning if I should report an intern that had some major shortcomings as I felt patient care was compromised. While I sympathize the learning process, I felt that there were dangers to the patients that perhaps the attendings should be aware of. I will name the resident "Alex". We saw multiple patients in *half* a day, and there were red flags in each of the visits.

1st visit. Spanish speaking patient had a virtual translator in the room. In the beginning of the visit, she nodded as if she comprehended what Alex was saying to her in English. Alex proceeded to tell the translator "just translate the parts that need to be translated". However, how can the translator know what needs to be translated?!? Alex decided to go through lab results purely in English, but patient showed confusion on her face and Alex continued to not use the translator. Additionally, when the physical exam was conducted, the patient could not follow any simple commands including "pull or push"

2nd visit. patient came in with symptoms of receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god. This patient had also previously seen a psychiatrist and was taking anti-psychotic which the patient stopped themselves. However, when I presented the patient to Alex, the resident simply dismissed it as a mental illness that all religious people suffer from. I was supposed to present on the patient to the attending, but instead decided to present themselves, because he wanted to "not make it sound like the patient was having delusions". However, when we reviewed the chart further, apparently Alex had seen the patient and was told the patient had a schizophrenic disorder. When Alex presented to the attending, they flipped the script entirely and talked about the delusions.

3rd patient. pregnant mother at 39w0d, G1P0000 was scheduled for induction next week to which she was very nervous about the induction and was wondering if she could wait a few days past the due date for chance natural birth despite being against medical advice. However, Alex kept misinterpreting the question and repeatedly said that induction takes a while and so the birth might happen perhaps 12-24 hrs past the due date, and that the mother needs to stick with the induction date. Alex , at one point, snapped at the mother. Alex did not offer shared decision making and the family was visibly upset and frustrated with Alex

While none of these anecdotes point to ideal patient care, I wouldn't say any rise to a patient safety concern that would warrant reporting. Learn from Alex's mistakes and maybe when you're an overworked resident you'll have some sympathy for him not meeting the ideal standard.

 

[mrbreakfast]

I agree with everyone else. Please be careful you do not conflate "I think this could have been done better" with "this is medically unsafe." Also keep in mind that is is possible you may have misread the situation, not the resident.

It's sad to say, but as you move up the ranks into residency and beyond you will come to realize that a lot of people in medicine do a crappy job. Everyone is taught to take a thorough history, review medications and labs, and come up with a thoughtful plan before acting, but some people do a much better job of that stuff than others. You learn both through positive example and negative example; take this as a learning experience, if nothing else.

 

[operaman]

I would not report. There is a 100% chance the attendings already know this kid sucks. The behaviors you describe are common to weak trainees and there is no way to hide that weakness from scrutiny. The translator thing and the delusion thing sound like someone who is being lazy or who is being told he’s inefficient and coping poorly by cutting corners.

There’s also an attending who is supervising and seeing these patients so I don’t think patient care is ultimately suffering even if the intern isn’t that good. Everyone knows interns don’t know sh-t from shinola, even the good ones, so the attending is surely looking over their shoulder.

Take it as a lesson on what not to do and know that when you suck, everyone else can tell. So don’t suck.

 

[Goro]

I would not report. There is a 100% chance the attendings already know this kid sucks. The behaviors you describe are common to weak trainees and there is no way to hide that weakness from scrutiny. The translator thing and the delusion thing sound like someone who is being lazy or who is being told he’s inefficient and coping poorly by cutting corners.

There’s also an attending who is supervising and seeing these patients so I don’t think patient care is ultimately suffering even if the intern isn’t that good. Everyone knows interns don’t know sh-t from shinola, even the good ones, so the attending is surely looking over their shoulder.

Take it as a lesson on what not to do and know that when you suck, everyone else can tell. So don’t suck.

The bolded sounds especially damning there, O-man!

You and the other wise attendings here have provided advice for the OP, but would it be redundant for the OP to hear from the attendings at Alex's institution how complaints would handled?

Clearly, you all have trained at different places but are on the same wavelength, but I'm wondering is there a specific institutional culture thing for situations like this? Teaching moment type of thing?

 

[operaman]

The bolded sounds especially damning there, O-man!

You and the other wise attendings here have provided advice for the OP, but would it be redundant for the OP to hear from the attendings at Alex's institution how complaints would handled?

Clearly, you all have trained at different places but are on the same wavelength, but I'm wondering is there a specific institutional culture thing for situations like this? Teaching moment type of thing?

I think the key here is that the student would really be out of line lodging a complaint about what boils down to Alex’s clinical skills. There’s not really a clear mechanism for this kind of reporting anywhere because it’s not really an appropriate thing for students to be passing judgement up hill so to speak. The student’s job is to be learning rather than critiquing. I just can’t imagine how this student could report this and not come across like a complete tool.

There are definitely reporting mechanisms for students to report poor teaching or other grievances that directly impact them as students. There are also clear mechanisms for reporting true patient safety concerns. The OP is about one step away from schoolyard tattling.

I’m sure the staff at OP’s institution would say the same thing. If you think about it, In this case you’d have someone who’s been a doctor for 6 months being criticized by someone who six months ago was whining about a preclinical lecture not being relevant to step 1. Best move for all is to focus on their own learning and Give only the feedback they’re actually qualified to give.

 

[deleted1100659]

The second one is the part im confused on; did he know they had a primary psychotic disorder and not start them on their home antipsychotic or what? People with schizophrenia can have some psychosis at baseline but if he purposely withheld her medications and she was decompensating, then that would have been concerning

 

[Dr. Anonymouss]

I agree with everyone else. What you are really scrutinizing is the the type of physician Alex is and how you believe he should do X, Y, and Z. If Alex isn't doing anything that is immediately jeopardizing patient safety then leave the scrutinizing to the attendings who are likely already aware of his performance, clinical skills, attitude, etc.

 

[Dr G Oogle]

Do not recommend reporting for 1)this is your opinion and nothing unsafe, just bad medicine, is going on 2) if this is a pattern, attendings and PD will already know about this and may already have a remediation plan.

If you do not think you are in a good learning environment you can go to your clerkship director and ask to be reassigned citing your experience

 

[Candidate2017]

Clearly, you all have trained at different places but are on the same wavelength, but I'm wondering is there a specific institutional culture thing for situations like this? Teaching moment type of thing?

As others have said, OP's post gives off the vibe they think they would've done a better job than the intern, rather than any actual safety issue. Overall, OP's description of the events are so subjective and confusing that it calls into question whether their perception of the actual events were accurate.

There is a subset of students who are eager to point out perceived shortcomings in others while being blind to their own lack of knowledge. This is where "put in my place" questions, assigning power point presentations, and having them see lots of patients and painstakingly critique their physical exam and presentations.

Medicine attracts some of these people. But med school also encourages this behavior because admin constantly teach students that randomly screaming "professionalism" and "patient safety" allows you to browbeat others even if you're a random secretary.

 

[Dral]

Agree with most on here. Those examples seem more like just cutting corners or just poor bedside manner. However, the first one could represent a patient safety concern if the patient definitely did not speak or understand English well and there was a significant lab abnormality (For example, if her A1C was elevated and Alex explained the ramifications of that). Rules about translators are technically a little strict if protocols are followed properly (example, an 18 year old who speaks English fluently and is in the room with their parent who does not speak/understand well should not technically serve as a translator.

 

[Goro]

There is a subset of students who are eager to point out perceived shortcomings in others while being blind to their own lack of knowledge.

Must be the same students who oh, well being in their first year, constantly tell us that the material we teach them won't be on boards.

 

[shaggybill]

Risk vs reward.

Reporting this brings risk.

Not reporting it brings no risk to you personally, and these patients are being seen by an attending physician.

Unless you see this intern doing something that will directly harm the patient if you don't intervene, it may be better to let it go and just get through the rotation. Sad state of affairs, but that's just the way it is.

As someone else already said, no doubt this intern is already on the program's radar.

 

[snooper]

How many hours/week, how many weeks without break is the intern working?

 

[DarkHorizon]

Reviewing your post history, you’re an M3. Is this a troll post? You’re contemplating reporting an intern to their attending for patient care issues? What do you know about patient care? Granted, I’m sure intern is borderline clueless, you’re in no position to report the intern. This isn’t your patient. It’s not even interns patient, you def don’t know more than the intern. Shared decision making? Really? Your perception, and what you think would have been proper care, is just like your opinion man.

Regardless of what the intern had to say, interns just follow the orders for the most part. Attendings make all the decisions and I’m sure they’re already aware of this interns short comings. If you did this on surgery or surgical subs, you’d instantly become a legend, and not in a good way.

Edit: Your post history indicates you failed two preclinical courses and were delayed to start your rotations due to poor nbme scores. You described your academic performance as “very poor”. I find your post quite ironic in light of your post history. I’m sure even you know that this is a really bad idea.

 

[Redpancreas]

Hi SDN forums,

Hope you all are enjoying yourselves- I am questioning if I should report an intern that had some major shortcomings as I felt patient care was compromised. While I sympathize the learning process, I felt that there were dangers to the patients that perhaps the attendings should be aware of. I will name the resident "Alex". We saw multiple patients in *half* a day, and there were red flags in each of the visits.

1st visit. Spanish speaking patient had a virtual translator in the room. In the beginning of the visit, she nodded as if she comprehended what Alex was saying to her in English. Alex proceeded to tell the translator "just translate the parts that need to be translated". However, how can the translator know what needs to be translated?!? Alex decided to go through lab results purely in English, but patient showed confusion on her face and Alex continued to not use the translator. Additionally, when the physical exam was conducted, the patient could not follow any simple commands including "pull or push"

2nd visit. patient came in with symptoms of receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god. This patient had also previously seen a psychiatrist and was taking anti-psychotic which the patient stopped themselves. However, when I presented the patient to Alex, the resident simply dismissed it as a mental illness that all religious people suffer from. I was supposed to present on the patient to the attending, but instead decided to present themselves, because he wanted to "not make it sound like the patient was having delusions". However, when we reviewed the chart further, apparently Alex had seen the patient and was told the patient had a schizophrenic disorder. When Alex presented to the attending, they flipped the script entirely and talked about the delusions.

3rd patient. pregnant mother at 39w0d, G1P0000 was scheduled for induction next week to which she was very nervous about the induction and was wondering if she could wait a few days past the due date for chance natural birth despite being against medical advice. However, Alex kept misinterpreting the question and repeatedly said that induction takes a while and so the birth might happen perhaps 12-24 hrs past the due date, and that the mother needs to stick with the induction date. Alex , at one point, snapped at the mother. Alex did not offer shared decision making and the family was visibly upset and frustrated with Alex

1. Sounds like a busy intern trying to cut corners. Mornings are tough with 10+ patients to chart review, see, meet with senior, and make plans on...and have it all synthesized prior to rounds to present. Day time is busy too with discharges, admits, etc. all coming in at once. I'm not saying you won't be better as an intern, but at this point you lack major perspective in to make any judgments as to what he is doing.

It sounds like what he lacks is critical thinking and prioritization elements of being an intern. Those things may come with experience and everyone progresses at different rates. You may be truly ahead of him in that aspect. I've met some medical students with better reasoning than interns, but It's not your place to comment on it as an M3. You may be right, but you may be wrong.

2. It's unclear what you mean here because you haven't typed it out coherently, but it sounds like there was some patient who had documented delusions (unless you alone elicited this history from her) and you mentioned it to him and he minimized it, but later changed his impression. This should be a positive, not a negative if your first concern is for the patient. If your first concern is for who was right first, then I could understand why the situation may irritate you.

I hardly see this as unsafe, and in fact literally don't even see where the mistake (in care) was made as the intern likely didn't have all the information at hand when you first discussed things with him. The mistake that was made was him making presumptions and dismissing your ideas/concerns. It's not good resident-teaching hygiene and residents actually have modules they go through mandated by ACGME where they're told explicitly not to do this. There seems to be some friction between the two of you if he had to decide to present the patient himself and say "not make it sound like the patient was having delusions". The dismissing your thoughts part can be addressed if you feel it is a pattern. It can be reported to the clerkship director who has likely had this issue with other students/residents before and can voice the concerns to the appropriate party. The part you should stay out of is making commentary as to how it's affecting patient care because you lack the context to make that determination.

3. It's been a while since I've had to answer questions related to anything OB and the way you phrased the situation leaves room for interpretation so I can't tell if you're just missing something and Alex knows what the patient is saying but is sticking to his point or if Alex is overconfidently giving the patient bad advice/misinterpreting the question. All I'll say here is if it is the latter, the attendings or senior residents definitely know about it from prior events. Patients tell attendings everything and they'll surely hear about it if someone is doing this consistently.

What I will advise though is whenever you plan to report something, think about your goal. What ultimately would you like to have changed? As a student, your responsibility is to learn unless there is a blatant error that none of these situations seem to be. If you feel like Alex is not providing a good learning environment for you and are advocating for a better one that will be well received. Your interpretation of what's medically correct or not has nothing to do with that though.

 

[Lawpy]

Reviewing your post history, you’re an M3. Is this a troll post? You’re contemplating reporting an intern to their attending for patient care issues? What do you know about patient care? Granted, I’m sure intern is borderline clueless, you’re in no position to report the intern. This isn’t your patient. It’s not even interns patient, you def don’t know more than the intern. Shared decision making? Really? Your perception, and what you think would have been proper care, is just like your opinion man.

Regardless of what the intern had to say, interns just follow the orders for the most part. Attendings make all the decisions and I’m sure they’re already aware of this interns short comings. If you did this on surgery or surgical subs, you’d instantly become a legend, and not in a good way.

Edit: Your post history indicates you failed two preclinical courses and were delayed to start your rotations due to poor nbme scores. You described your academic performance as “very poor”. I find your post quite ironic in light of your post history. I’m sure even you know that this is a really bad idea.

Ouch, that is a pretty brutal takedown of OP.

 

[Browns99]

Ouch, that is a pretty brutal takedown of OP.

Yes, but totally spot on....go look at the OP's prior posts and then come back and see if there is any credibility to what he/she(OP) is saying.

 

[RangerBob]

I had an extremely unprofessional attending for one rotation. I did the same thing you should do if you have concerns about this resident--discuss it with your clerkship director first. In my case, my director was concerned so they had me meet with the attending's chair. They found out other students had observed the same behavior and now students no longer rotate with that attending. So change can happen, but you should go through the appropriate chain of command is. Unless it's the type of thing that needs to be acted on immediately--like you're IM intern is deciding to open up a patient's sternotomy wound at the bedside.

The interpreter situation is quite bad. And the interns' attending may or may not know. But that patient has a right to know what's going on.

From the very limited data you provide, the second patient sounds a bit more like someone in the midst of a manic episode, not just psychotic. If so, that's not something one should miss, as that can be reason alone to involuntarily admit someone. So can schizophrenia, but mania is a different ballgame. I hope the attending was able to delve more into it and clarify if that patient was a clear threat to themselves/others.

So if you're concerned, talk to your clerkship director, and do it in a non-accusatory type of way, ie. "my intern handled this situation this way--it doesn't seem appropriate to me, but I know I'm still learning. What would you have done?"

 

[Tenk]

Snitches get stitches.

You have far more to lose and nothing to gain here. Better to move on.

 

[Miles Gloriosus]

Hi SDN forums,

Hope you all are enjoying yourselves- I am questioning if I should report an intern that had some major shortcomings as I felt patient care was compromised. While I sympathize the learning process, I felt that there were dangers to the patients that perhaps the attendings should be aware of. I will name the resident "Alex". We saw multiple patients in *half* a day, and there were red flags in each of the visits.

1st visit. Spanish speaking patient had a virtual translator in the room. In the beginning of the visit, she nodded as if she comprehended what Alex was saying to her in English. Alex proceeded to tell the translator "just translate the parts that need to be translated". However, how can the translator know what needs to be translated?!? Alex decided to go through lab results purely in English, but patient showed confusion on her face and Alex continued to not use the translator. Additionally, when the physical exam was conducted, the patient could not follow any simple commands including "pull or push"

2nd visit. patient came in with symptoms of receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god. This patient had also previously seen a psychiatrist and was taking anti-psychotic which the patient stopped themselves. However, when I presented the patient to Alex, the resident simply dismissed it as a mental illness that all religious people suffer from. I was supposed to present on the patient to the attending, but instead decided to present themselves, because he wanted to "not make it sound like the patient was having delusions". However, when we reviewed the chart further, apparently Alex had seen the patient and was told the patient had a schizophrenic disorder. When Alex presented to the attending, they flipped the script entirely and talked about the delusions.

3rd patient. pregnant mother at 39w0d, G1P0000 was scheduled for induction next week to which she was very nervous about the induction and was wondering if she could wait a few days past the due date for chance natural birth despite being against medical advice. However, Alex kept misinterpreting the question and repeatedly said that induction takes a while and so the birth might happen perhaps 12-24 hrs past the due date, and that the mother needs to stick with the induction date. Alex , at one point, snapped at the mother. Alex did not offer shared decision making and the family was visibly upset and frustrated with Alex

Talk to a senior resident first or a chief resident. Don’t go straight to attending.
If intern as bad you make them, senior resident would have known of past transgressions and your red flag complaint would be another data point for them. If you go straight to attending, you could be theoretically throwing the senior resident under the bus

 

[Mass Effect]

First I commend you for recognizing in what can go wrong in practice from what you have learned theoretically in the classroom. Learn from it and make sure when you are practicing, don 't do what the intern is doing.

I'm guessing that you are a MS3 or MS4? I would highly recommend that unless you witness said intern do something so egregious like ordering the wrong medication that would harm or kill the patient, physically assault the patient, etc., to keep your nose down and not make any waves. It's hard for me to advise this because I have also witness things during clerkships that I thought about reporting but did not because of unspoken retaliation. And it does happen.

If the upper residents or attendings do not already know of the intern's transgressions, eventually they will find out and will/should act accordingly. You as the MS3/4 just continue to act professionally and keep your nose clean. The rest of your time in medschool will be less stressful for it.

And this is the code of silence that eventually kills patients. Let's just all pray it isn't our loved one who gets killed when we all remained silent.

Look up Dr. Death.

Note I am NOT saying this intern in this story is going to kill someone. I'm saying the code of silence in general is not good.

 

[Mass Effect]

I think the key here is that the student would really be out of line lodging a complaint about what boils down to Alex’s clinical skills. There’s not really a clear mechanism for this kind of reporting anywhere because it’s not really an appropriate thing for students to be passing judgement up hill so to speak. The student’s job is to be learning rather than critiquing. I just can’t imagine how this student could report this and not come across like a complete tool.

There are definitely reporting mechanisms for students to report poor teaching or other grievances that directly impact them as students. There are also clear mechanisms for reporting true patient safety concerns. The OP is about one step away from schoolyard tattling.

I’m sure the staff at OP’s institution would say the same thing. If you think about it, In this case you’d have someone who’s been a doctor for 6 months being criticized by someone who six months ago was whining about a preclinical lecture not being relevant to step 1. Best move for all is to focus on their own learning and Give only the feedback they’re actually qualified to give.

Meh, I don't agree that it's schoolyard tattling or that the intern is just a poor intern. Not using a translator for a patient who clearly needs one is a big deal as it not only sets the hospital up for liability from a risk management standpoint but it also neglects informed consent. And it's just not cool that patients who need a translator aren't allowed to know their medical labs because of an incompetent intern. I actually think this is a big enough deal that it should be addressed in the end of rotation evaluation or anonymously at the end of the academic year.

The other two examples are examples of a ****ty intern, but the translator one is a big deal. My opinion only.

 

[Dr. Anonymouss]

And this is the code of silence that eventually kills patients. Let's just all pray it isn't our loved one who gets killed when we all remained silent.

Look up Dr. Death.

Note I am NOT saying this intern in this story is going to kill someone. I'm saying the code of silence in general is not good.

I understand your point, but assuming that the issues that OP stated were the worst situations by the intern then I don't see how it constitutes bringing it up. We can all agree that if patient safety was involved or if there was significant incompetence then it should be addressed, but this is a gray area where I think OP should just stay in their own lane.

 

[SpoiledMilk]

Yah. I never advocated for a "code of silence." I distinctly said that if OP witnessed harm to patient safety, then OP should report. The 3 scenarios that OP described do not rise to the level of reporting, as many other commenters said, some more gently than others...And what I witnessed in clerkships as a MS3 were also subjective, hence I never reported it. If I had witnessed harm/injury to patients, then I would have reported them.

 

[ortnakas]

Don’t go straight to the attending; bad move.
There is, however, a way to subtly bring it to the attention of this intern’s senior though- couch it as a learning opportunity, for you.

“Alex and I struggled getting an exam on the spanish speaking patient, any tips on what we should do in the future” lets them know Alex didn’t do the best job and gives them a chance to work with him. “Alex did a bad job” especially to the attending just isn’t a good look for you.

 

[Mass Effect]

I understand your point, but assuming that the issues that OP stated were the worst situations by the intern then I don't see how it constitutes bringing it up. We can all agree that if patient safety was involved or if there was significant incompetence then it should be addressed, but this is a gray area where I think OP should just stay in their own lane.

Yah. I never advocated for a "code of silence." I distinctly said that if OP witnessed harm to patient safety, then OP should report. The 3 scenarios that OP described do not rise to the level of reporting, as many other commenters said, some more gently than others...And what I witnessed in clerkships as a MS3 were also subjective, hence I never reported it. If I had witnessed harm/injury to patients, then I would have reported them.

I don't think failing to use a translator is harmless or subjective frankly.

 

[SpoiledMilk]

I'm sure the intern had to present the patient to his attending/chief resident both of whom were aware of the lab results and during rounds the attending/chief would have made the patient aware of any issues resulting from the lab results.

Since we weren't there, OP believed the patient had a confused look. OP never indicated the patient told the translator they didn't understand what the intern was saying in Spanish. We weren't there, hence it becomes a he said/she said situation based on OP's perception that the patient was confused.

 

[ACSurgeon]

And this is the code of silence that eventually kills patients. Let's just all pray it isn't our loved one who gets killed when we all remained silent.

Look up Dr. Death.

Note I am NOT saying this intern in this story is going to kill someone. I'm saying the code of silence in general is not good.

Good point. We need to empower the students. We’ve done a really good job empowering nurses, and that has paid dividends to improve patient safety. As a matter of fact, part of the student’s grade needs to be directly related to saving a patient from a mean/lazy/bad doctor. After all, only 10% are supposed to get honors, so that could be the way to find the top 10

 

[Goro]

Snitches get stitches.

You have far more to lose and nothing to gain here. Better to move on.

I agree with the second point and the education provided to me by the wise attendings, but Tenk, really, we're not in the 4th grade.

 

[Tenk]

I agree with the second point and the education provided to me by the wise attendings, but Tenk, really, we're not in the 4th grade.

Sure felt like it on some rotations….

 

[sean80439]

Hi SDN forums,

Hope you all are enjoying yourselves- I am questioning if I should report an intern that had some major shortcomings as I felt patient care was compromised. While I sympathize the learning process, I felt that there were dangers to the patients that perhaps the attendings should be aware of. I will name the resident "Alex". We saw multiple patients in *half* a day, and there were red flags in each of the visits.

1st visit. Spanish speaking patient had a virtual translator in the room. In the beginning of the visit, she nodded as if she comprehended what Alex was saying to her in English. Alex proceeded to tell the translator "just translate the parts that need to be translated". However, how can the translator know what needs to be translated?!? Alex decided to go through lab results purely in English, but patient showed confusion on her face and Alex continued to not use the translator. Additionally, when the physical exam was conducted, the patient could not follow any simple commands including "pull or push"

2nd visit. patient came in with symptoms of receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god. This patient had also previously seen a psychiatrist and was taking anti-psychotic which the patient stopped themselves. However, when I presented the patient to Alex, the resident simply dismissed it as a mental illness that all religious people suffer from. I was supposed to present on the patient to the attending, but instead decided to present themselves, because he wanted to "not make it sound like the patient was having delusions". However, when we reviewed the chart further, apparently Alex had seen the patient and was told the patient had a schizophrenic disorder. When Alex presented to the attending, they flipped the script entirely and talked about the delusions.

3rd patient. pregnant mother at 39w0d, G1P0000 was scheduled for induction next week to which she was very nervous about the induction and was wondering if she could wait a few days past the due date for chance natural birth despite being against medical advice. However, Alex kept misinterpreting the question and repeatedly said that induction takes a while and so the birth might happen perhaps 12-24 hrs past the due date, and that the mother needs to stick with the induction date. Alex , at one point, snapped at the mother. Alex did not offer shared decision making and the family was visibly upset and frustrated with Alex

You should keep your head down and stay in your lane.
If we take your story at face value -
1) MANY of my patients are garbage at following simple commands, with english as their first and ONLY language when attempting to do a neuro exam. Hell getting people to breath through their mouth for respiratory exam is hard.
2) You're mad because the intern realized he made a mistake (or your presentation was not clear) and re-presented the appropriate information.
3) Shared decision making - LOL. You aren't involved in any of that and I guarantee the intern isn't either other than relaying their attendings advice. Patient's are upset at doctors all the time when they don't like what they hear.

Tl;dr get over yourself.

 

[bigloley]

The translator incident is illegal under the ACA and a violation of civil rights. As a result, malpractice insurances are waived if inadequate translator services are used. This is not only poor care but also makes the program and attending liable.

Would report, but would try to do it anonymously or via a safe route given the power dynamic.

 

[mvenus929]

Don’t go straight to the attending; bad move.
There is, however, a way to subtly bring it to the attention of this intern’s senior though- couch it as a learning opportunity, for you.

“Alex and I struggled getting an exam on the spanish speaking patient, any tips on what we should do in the future” lets them know Alex didn’t do the best job and gives them a chance to work with him. “Alex did a bad job” especially to the attending just isn’t a good look for you.

If this occurred in the clinic setting (which is what it sounds like to me), there usually isn't an intermediary between the intern and the attending.

 

[Redpancreas]

It

Meh, I don't agree that it's schoolyard tattling or that the intern is just a poor intern. Not using a translator for a patient who clearly needs one is a big deal as it not only sets the hospital up for liability from a risk management standpoint but it also neglects informed consent. And it's just not cool that patients who need a translator aren't allowed to know their medical labs because of an incompetent intern. I actually think this is a big enough deal that it should be addressed in the end of rotation evaluation or anonymously at the end of the academic year.

The other two examples are examples of a ****ty intern, but the translator one is a big deal. My opinion only.

The point is that the medical student (especially M3) lacks context to make much out of an intern's performance. Take the first example. Was this before rounds, after rounds, on call? How do we know the resident didn't go back? Heck, when I had non-English patients as an intern, I conveyed the very essentials to the patient via translator and moved on with a mental note to come back and have a full comprehensive discussion or else I would have spent 2/3 of my entire pre-rounding time on one patient. Heck, I'd come back after sign out if I had to. Medical students in many places are dismissed quite early relative to residents and are missing lots of patient care.

Take the second example. Was this pre-rounds where OP saw/pre-rounded on the patient whereas the intern hadn't? Hallucinations as a primary issue (while to be taken very seriously) aren't the first thing you think about on a differential on a medical/surgical unit because presumably those patients would be triaged to an inpatient psychiatric facility. Obviously if you walk into the room and the patient is presenting that way, you need to change your assessment...and OP even says that once the intern gathered more information, he or she changed their assessment demonstrating the intern is not ignoring things. It seems more like OP is just mad the intern disregarding their initial impression. At the end of the day, we're all here to do the best for the patient, not focus on who was right. Obviously there's some friction between these two and we don't know the full story.

Regarding the last example, it's still not clear whether Alex is super oblivious or the medical student is just missing something. I wouldn't put it past either of them so it's a tough call.

OP IMO comes off as pretty naive/immature. Their first instinct is looking to identify incompetence in someone at a higher level than them when they should be worrying about their own education. If OP gave three examples of how the intern neglected a specific group (ie Spanish speakers), that would warrant a complaint as that's a professionalism concern. In this case, it seems like OP is trying to make a holistic argument that the intern is incompetent. That's not OP's job or in OP's scope to assess.

 

[Lawpy]

The translator incident is illegal under the ACA and a violation of civil rights. As a result, malpractice insurances are waived if inadequate translator services are used. This is not only poor care but also makes the program and attending liable.

Would report, but would try to do it anonymously or via a safe route given the power dynamic.

This is a major point to consider. I know SDN likes to tear OP apart but come on, the translator issue is a major problem and i’m shocked people are minimizing this issue

 

[ortnakas]

If this occurred in the clinic setting (which is what it sounds like to me), there usually isn't an intermediary between the intern and the attending.

I thought it was the hospital in which case there’d be a senior resident. Either way, posing it as a question lets a supervisor know and educates OP without making OP an obnoxious narc.

 

[Mass Effect]

It

The point is that the medical student (especially M3) lacks context to make much out of an intern's performance. Take the first example. Was this before rounds, after rounds, on call?

Makes no difference. You are required to use a translator for all information when the patient doesn't speak English.

How do we know the resident didn't go back? Heck, when I had non-English patients as an intern, I conveyed the very essentials to the patient via translator and moved on with a mental note to come back and have a full comprehensive discussion or else I would have spent 2/3 of my entire pre-rounding time on one patient.

That's different than what the OP is saying, unless you're saying that when you came back to have the "full comprehensive discussion" you didn't use a translator?

Take the second example. Was this pre-rounds where OP saw/pre-rounded on the patient whereas the intern hadn't? Hallucinations as a primary issue (while to be taken very seriously) aren't the first thing you think about on a differential on a medical/surgical unit because presumably those patients would be triaged to an inpatient psychiatric facility.

This is actually dangerous thinking and also not congruent with the scenario the OP laid out. The OP said "receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god". If a psychotic illness isn't on your differential regardless of what unit you're on, you're a ****ty intern. That isn't necessarily reportable, but it's a ****ty intern regardless.

Obviously if you walk into the room and the patient is presenting that way, you need to change your assessment...and OP even says that once the intern gathered more information, he or she changed their assessment demonstrating the intern is not ignoring things. It seems more like OP is just mad the intern disregarding their initial impression. At the end of the day, we're all here to do the best for the patient, not focus on who was right. Obviously there's some friction between these two and we don't know the full story.

I agree with this.

OP IMO comes off as pretty naive/immature.

I don't agree with this. I think the OP is asking for guidance. We know there are incompetent interns out there and I do think some MS 3 and 4's can spot one when it comes to patient encounters.

Their first instinct is looking to identify incompetence in someone at a higher level than them when they should be worrying about their own education. If OP gave three examples of how the intern neglected a specific group (ie Spanish speakers), that would warrant a complaint as that's a professionalism concern. In this case, it seems like OP is trying to make a holistic argument that the intern is incompetent. That's not OP's job or in OP's scope to assess.

I don't understand the hierarchy argument. What the OP is commenting on is something that frankly med students even pre-clinical would be turned off by. Hell, it's something that patients write reviews over. You don't need to be a board certified attending to know you use a translator for all information conveyed with a patient who doesn't speak English. I agree that it isn't in the OP's scope to assess competence, but just because they're a med student doesn't mean they don't get to have an opinion on the patient care they witnessed with their own eyes and ears.

 

[Redpancreas]

Makes no difference. You are required to use a translator for all information when the patient doesn't speak English.



That's different than what the OP is saying, unless you're saying that when you came back to have the "full comprehensive discussion" you didn't use a translator?



This is actually dangerous thinking and also not congruent with the scenario the OP laid out. The OP said "receiving messages from god, feeling unlimited power, feeling she can climb mountains, feeling like she is connecting with her in her soul, feeling like she is commanded by god". If a psychotic illness isn't on your differential regardless of what unit you're on, you're a ****ty intern. That isn't necessarily reportable, but it's a ****ty intern regardless.



I agree with this.



I don't agree with this. I think the OP is asking for guidance. We know there are incompetent interns out there and I do think some MS 3 and 4's can spot one when it comes to patient encounters.



I don't understand the hierarchy argument. What the OP is commenting on is something that frankly med students even pre-clinical would be turned off by. Hell, it's something that patients write reviews over. You don't need to be a board certified attending to know you use a translator for all information conveyed with a patient who doesn't speak English. I agree that it isn't in the OP's scope to assess competence, but just because they're a med student doesn't mean they don't get to have an opinion on the patient care they witnessed with their own eyes and ears.

You're essentially saying it doesn't take someone with an MD degree to recognize when someone’s treating someone else poorly which I agree with. I still don't know if this is worth reporting.

You could make the strongest argument I feel with point #1 mainly because OP is not using the translator effectively. As someone mentioned, not using a translator altogether is illegal/discrimination, but I don’t know how you make that claim as maybe the intern foolishly assumed the translator magically knew medicine rather than just that they were cutting corners…or maybe it was somewhere in between…then there’s the part where intern likely had to circle back and talk with the patient when the nurse paged the resident team to notify them the patient had no clue what was said to them. It’s not like a clinic visit where the patient leaves after you talk with them. Interns usually see patients several times a day many times after medical student leave.

It’s also easier to read body language of others when you’re not the one doing the talking and I’m sure there have been times where OP has made mistakes too and made patients/others confused or nervous without realizing it. It happens with nearly every doctor...

I get complaints from patients daily during pre-rounds about how the other doctors (attendings, fellows, residents) had poor bedside manner. You work long enough though and you realize patients are likely saying the same stuff about you behind your back when talking to other doctors. “I don’t know who that doctor was, I see so many doctors”, “he confused me/scared me”, etc. This realization comes with experience as students and newer residents who've yet to have patients crap on them yet think every patient's negative body language or feedback is a knock on the physician. Every feedback item is valuable because it offers an opportunity to be even better, but one should not take the comments to heart.

Example #2 just seems like the resident didn't trust OP's judgment and that ticked OP off. Most residents don't, but some are better than others at expressing it. I don’t really know what to make of example #3, but assuming you understood the question better than the resident, it sounds like the resident is being paternal or misunderstanding the patient. Again, you have to realize that it’s easier for an observer to interpret things more clearly as they’re not so focused on communicating their message but have time to sit back and observe the room.

Ultimately, if OP chooses to report, what is the end goal? I don't see a constant theme in these examples that you can encapsulate into a modifiable change, unless you are going to make the argument that the resident looks down on marginalized patient (Hispanic speaking, those with mental illness, etc.). If you think that, I would gather some more examples before reporting it so it really comes across clearly.

OP, kind of weird to be in these shoes now. For entertainment or introspective value, check out this thread I made about a medical student I ended up reporting. (tl;dr the medical student was likely expelled).

 

[Goro]

Many great teaching points in this thread; for this, I am grateful to our wise SDN attendings and residents!

Quite a while ago, the wise Law2Doc once posted that "you learn your craft in residency". I've never forgotten that.

 

[Redpancreas]

Bizarre Medical Student

I am a resident who has noticed strange behavior from a particular medical student over the past few months and just wanted to share my experience and solicit advice on how to deal with this case. This medical student has been observed by me on two subsequent rotations we happen to...

forums.studentdoctor.net

OP, kind of weird to be in these shoes now. For entertainment or introspective value, check out this thread I made about a medical student I ended up reporting. (tl;dr the medical student was likely expelled).

 

[VenusinFurs]

The attending already are likely aware of Alex is struggling and patients are allowed to make their own calls when it comes to not liking how a doctor talks to them, you don’t have to do it for them.

 

[hamstergang]

then there’s the part where intern likely had to circle back and talk with the patient when the nurse paged the resident team to notify them the patient had no clue what was said to them. It’s not like a clinic visit where the patient leaves after you talk with them.

Except that I'd be shocked if OP was not about a clinic visit. Nothing indicates that this was inpatient, and he talks about each encounter as a visit.