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Spandorfer J, Pohl C, Nasca T, Rattner SL, eds. Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge: Cambridge University Press; 2010.

Thomas Jefferson University

Video: Commitment to Professional Responsibilities | Commentaries

A Faculty Perspective

On one level, the responsibility of the student is simple. As a member of the health care team, he or she is morally obliged to ensure that accurate information is passed among team members to ensure optimal care of the patient. If we wish to incorporate the aviation concept of crew resource management into medical practice, then any member of the healthcare team, no matter how junior, should feel free to speak up and note an incorrect piece of data that is being shared.

However, the scenario portrayed here is not the simple matter of as a single test result being mistakenly recounted by a busy resident. Nor is it an example of "roundsmanship" where the resident smoothly throws out a "ballpark" number -- "The potassium was 4.3" when the result was actually 4.1 -- in order to give the appearance of total control of their service. The latter is a somewhat less egregious, although still not completely innocent, behavior.

Rather, this resident is engaged in a behavior which is, at the very least, unethical, and is, very likely, potentially dangerous for the patient. A missed element of the history of present illness, of past history, or of a pertinent physical finding, could lead to a very real error in diagnosis or a delay in care. It is also likely that this episode does not represent just a one-time misstep. A resident who glibly fabricates false information has probably done so many times before.

I believe that it is a lot to ask of a student to try and to remediate this problem on his or her own and am not confident that the efforts, described by the student in the commentary below, would be successful. Although an adept student may be able to artfully work the true details (or lack thereof) during the rounding session with the resident and attending, the underlying behavior of the problem resident has not been addressed. It is furthermore unlikely that a junior student would be able to meaningfully discuss this problem with the resident after the event occurred. The well-established medical hierarchy almost certainly ensures that counseling efforts will not be accepted or viewed constructively when directed up the chain of command.

Therefore, the student is placed in the very uncomfortable position of acting as a whistle-blower. He or she must bring the problem to the attention of a superior, at the risk of jeopardizing that resident's job or professional standing in the program. Not understanding how a residency program or, indeed, how the entire medical profession, deals with ethic problems such as these, adds to the student's unease in this situation. Furthermore, the student may believe that by being a "snitch" they are jeopardizing their own standing within the department, with a resulting negative impact on his or her own career.

My recommendation for the student is to immediately bring this episode to the attention of the clerkship or program director. Trying to directly report the misbehavior to the particular attending could, depending on that attending, lead to a less than ideal handling of the situation. Rather, the clerkship director or program director should hear the students concerns. Then, in collaboration with the patients' attending, a re-interview and examination of the patient can elicit what was or wasn't performed by the resident. Directed questions such as "And when the resident asked you about..." or "When the resident performed the rectal examination..." will quickly expose the fabrications of the resident. The problem can then be addressed directly by the attending or program director, without exposing the student to undue retribution or recriminations by the resident, or by others in the program. The behavior of the problem resident can then be closely reviewed and, hopefully, appropriate remediation may be achieved.

We must educate our clerkship directors and prepare them to handle these ethical dilemmas. We must also let our students know that they have a safe pathway through which they can share their concerns and encourage them to make the morally correct choices. By working together, we can develop the just culture that will allow medicine to provide safe and ethically sound care for all patients.

John C. Kairys, M.D. FACS
Vice Chairman for Education, Department of Surgery
Jefferson Medical College