Declining care from physicians in training

Recently, I had the fortune of hearing the tale of Bob and his bum knee.

It all started when Bob picked me up at the end of a busy clinic day in his neon orange Subaru.  Given that this particular shared car service promotes friendly conversation, Bob started up the gab by asking me what position I held in the medical center.  After describing my work as a resident physician in internal medicine, Bob nodded in acknowledgment and began to tell his story.

The setup

Bob commenced this unsolicited anecdote with a description of his days back in Oconomowoc, WI, just before the recession hit nationwide.  After only a short time looking for a job, Bob received what he described as a decent offer to work in marketing.  Given the fact that his mother was ill and he had ultimate plans to move out west, he decided to pass up on the offer and wait a few more months before reentering the workforce.

The rest of Bob’s story unraveled like a made-for-TV movie: his mother’s health declined sooner than anticipated and, sans employment in the midst of the market crisis, he ultimately forged ahead to San Francisco.  After several months of odd jobs in construction and landscaping, Bob noticed one of his knees swell “to the size of a basketball” and was no longer able to support himself given the new disability.  Given his lack of health insurance, he went to the county hospital for further workup of his knee.

Here is when my ears started to prick up.

He went on to describe how a young woman, identifying herself as a resident physician, had him change into a gown and reveal the swollen joint.  After preliminary imaging and a thorough examination, the resident explained to Bob that the knee would have to be drained and likely injected with an anti-inflammatory medication.  She described the risks and benefits of the procedure, had Bob sign a consent form and began preparing the clinic room for the minor procedure.

Bob, unaccustomed to playing the role of a patient in any hospital let alone a teaching hospital, was unfamiliar of the resident title and unaware of the significance it had in the spectrum of clinical training.  Through further questioning, he soon discovered that this physician was only a few years out of medical school and had done only a handful of this type of knee procedure.  Upon realizing this, he politely asked to postpone the procedure until a more experienced physician was available.  Several hours later, a supervising physician drained Bob’s knee, and he was discharged with a “brand new life.”

Bob made sure to throw two thumbs up as he revealed the well-healed knee to me before driving off to his next customer.

The conflict

Well after seeing the last of Bob and his bum knee, his story stuck with me.  At first I was angry over Bob’s decision to deny care from a capable physician in training.  I won’t lie that I briefly felt that Bob’s lack of insurance and admission to a teaching hospital waived his right to make the demands he had made.

But then I thought about Bob’s situation.  Here’s a guy who could not afford an operator error on his injured knee given that he was living from paycheck to paycheck off physical labor.  He had no experience with teaching hospitals and little understanding of the role of a resident physician.  Furthermore, his insurance status should have had no place in limiting what questions and concerns he could voice with regard to his treatment.  His decision to receive the most skilled care he could get was understandable.

And here lies the resident’s dilemma: If all patients had the same resolution to bypass care from physicians in training, how are newly-minted doctors able to sufficiently train in clinical medicine?

What steps can be made to close the communication gap between patients unaccustomed to teaching hospitals and the house staff (resident and intern physicians) who care for them?

The solution

There is undeniable room for improved communication when it comes to defining roles and setting expectations on how care is delivered in a teaching hospital.

To start, every member of a newly admitted patient’s health care team should introduce themselves and their distinct roles as health care providers as early as possible in the patient’s hospital stay.

There are often many members of a health care team in a teaching hospital and it is not uncommon for patients to get confused over titles and levels of medical expertise.  The team should therefore write their names and roles on any available board in the patient’s room and/or give out business cards to ensure transparency.   Patient concerns about the level of training and clinical experience of providers should be answered as early as possible.

For patients like Bob who have little experience with teaching hospitals, there may be a need for additional educational interventions such as pamphlets or brief educational videos describing the fundamental role that resident physicians and medical students will play in their care prior to meeting the medical team.

Take home point

Should I ever have the opportunity to ride with Bob again, I plan to ask him a few questions: If he was notified that he was in a teaching hospital prior to meeting the resident physician, would he be have been more amenable to having the procedure done by her?  Does he plan to avoid teaching hospitals from now on knowing that most of the physicians are in the midst of their medical training?  If he had to be treated by a team that included residents and medical students, what would make him most comfortable with the way his care was delivered?

In order to mitigate tales similar to Bob and his bum knee, teaching hospitals need to be more cognizant of the potential disconnect between patient expectations of care delivery and house staff need to provide direct patient care.

*The patient’s demographic information in this article was changed to protect identity and assure anonymity.

Brian J. Secemsky is an internal medicine resident who blogs at the Huffington Post.  He can be reached on Twitter @BrianSecemskyMD and his self-titled site, Brian Secemsky MD. This article was originally written for the American Resident Project.

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