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2013 YP Award Essay 5
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2013 Winner - Essay 5

The Doctors Company Foundation Young Physicians Patient Safety Award

In a watery voice, with hands unconsciously held in a pleading position, Mrs. D explained that she and her husband had traveled for more than 48 hours to see Dr. W because he was her last hope. Mr. D, her once high-functioning husband, had physically and mentally deteriorated rapidly over the course of several months, and Dr. W had promised to figure out what was wrong with Mr. D.


As a third-year medical student on one of my first rotations, I was still unsure of what my role on the medical team was supposed to be. I took my cue from the residents, who were in deathly awe and fear of Dr. W, a world-renowned expert on an extremely rare disease. Patients flew in from all over the world for his trademark four-day outpatient workup. Dr. W had trained at highly prestigious institutions during an era when the medical culture assumed that attending physicians were never wrong and the “teaching” of residents and students consisted of shaming them for their lack of knowledge in front of everyone, including the patients. As had been done to him, presumably, he now did to his subordinates. He expected perfection; anything not done according to his specifications was cause for public humiliation. More importantly, there was no room for questions, which would have been taken for insolence or plain stupidity. When residents asked questions, they were rewarded with icy stares, sarcasm, or additional work. All of this culminated in total acceptance of everything that Dr. W said – the residents were little more than meek servants scurrying to do the bidding of their master.


Mr. D was subjected to an array of invasive imaging and diagnostic procedures, none of which resulted in a conclusive diagnosis. Yet at the end of the standard four days’ outpatient workup, Dr. W concluded that Mr. D should return home and wait for the rest of the test results. He reassured Mrs. D, saying that the team would be in touch. She glanced over at me briefly with a searching look, questioning worry in her eyes. I had a sinking feeling that Mr. D needed much more than the warm reassurances echoed around the room by the care team, but I thought: if the residents are in agreement with Dr. W’s plan, who am I – a medical student in my first couple of months on wards – to raise concerns?


Mr. and Mrs. D flew back home on a plane the next day.

Several days later, on the last day of my rotation, I presented his case to another attending, Dr. T, during teaching rounds. After hearing his case presentation, she was incredulous about what we had (or, more accurately, had not) done for Mr. D, and her hard questions confirmed my worst suspicions.


“What did you do for the patient therapeutically?” Nothing.


“Why was he sent home – on a plane, no less – when he so obviously needed to be hospitalized for further workup?” I was unsure – Dr. W had said so, and the residents had not disagreed.


“Did you recommend any further workup for him?” ….No?


Dr. T sat back in disbelief. “CALL HIM. Tell him to come back. He’s going to die if you don’t do anything for him.”


Several months later, I searched for him online out of a need for closure. His obituary appeared. “Mr. D is survived by his wife.”

I thought back to the first day I had met her, when she had entrusted herself and her husband to us. She and I had both been naive, clinging to the belief in the absolute infallibility of Dr. W. But the painful experience of Mr. D’s subpar care had shown me exactly how fallible even the best can be. By perpetuating a culture of humiliating the subordinates, Dr. W had suppressed any meaningful discussion about Mr. D’s differential and treatment; Dr. W had set himself up as the only voice in the room, which meant that when he was wrong, he was VERY wrong. The parallels of the situation reminded of the captain of the KLM Boeing 747, who, on that fateful day in 1977, ignored his first officer when the first officer questioned the captain’s decision to take off with limited information and visibility. The result was a horrific plane crash that claimed 538 lives.


Medicine as a field has exploded with new information; while potentially life-saving for patients, this also means that no single medical professional can afford to be a “lone ranger.” The culture of promoting patient safety started with the rightful questioning of rigid hierarchies – indeed, patient safety has modeled itself after the airlines’ industry sweeping changes in the aftermath of the KLM plane crash. However, experiences like mine show that there remains much to do to encourage a “just culture” and blame-free environment. It highlights the importance of having a zero-tolerance policy for discourteousness or nonprofessional attitudes, even (or especially) towards subordinates. Every effort needs to be made to promote a team approach to patients.


Personally, the experience showed me the importance of each member of the medical team taking responsibility for the patient’s care, no matter how inexperienced one might be. In my subsequent rotations, I have taken it upon myself to research the conditions of the patients that I am responsible for and to review the literature about standards of care for their various conditions. Now, when I disagree with the residents or attending physicians’ plan of care, I do not hesitate to speak up – after all, medical students are well-positioned to advocate for their patients because they are usually the ones spending the most time with them. Moreover, the worst that can happen is that the attending may disagree with my ideas, but even that provides an invaluable learning opportunity. This experience has demonstrated to me the importance of open dialogue in ensuring patient safety, as well as the danger of rigid hierarchies. After having witnessed how silence kills, I must make my voice heard for my patients.


*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.

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