My department had a problem that harmed patients on at least a weekly basis. It was well-known, but it seemed there was no viable solution.

My supervising attending was in his seventies and highly regarded at my hospital, having held powerful administrative positions for decades. About ten or so years ago, he stepped down from running the hospital, and found a comfortable “retirement job” in my department, where his daily routine consisted of arriving at noon to have lunch with his longtime friend, and supervising residents in the afternoon. Although the workload on his service was light, it was not unusual for a polite resident to stay in the workroom with him well into the evening, to hear lengthy anecdotes about his life experience. He liked to refer to people by race (as in, “that young Hispanic fellow”), and seemed to enjoy engaging in discussion about prostitution. He found the receptive audience he craved in his residents.

While we often joked about these oddities and minor annoyances, we all knew there was a much more troubling issue. This attending spent the majority of his career on administrative duties and seemed to never regain the medical skills required for his new role. It was well-known among residents that he was severely deficient in basic clinical skills required of any physician. His inability to practice evidence-based medicine was unbelievable. He needed the daily assistance of residents to do even simple tasks. This meant he could not have been oblivious to his shortcomings, and the fact that he insisted on participating in patient care anyway was even more troubling.

A day working with this attending was somewhere between a nightmare and a bad joke. At the end of the day, I used to go home and mourn for patients who may have been harmed by his poor decisions, and feel disgusted at myself for being an accessory to this egregious misconduct. Many bad calls were made. Many patients received necessary tests or incorrect treatments as a result.

Conscientious residents often tried to surreptitiously determine the correct course of action by consulting other physicians and even senior nursing staff, or independently researching the topic. Then they would attempt to steer this attending toward that direction. Of course, this was a risky pursuit. Once, when a resident questioned a decision this attending made, in a burst of rage, he pounded on a desk and declared that this resident should be dismissed from his position for insubordination. The resident was not dismissed, but we knew it was well within his power to give us hell.

While our hospital, like most others, technically had a system in place to identify and report patient safety issues, reality is much more complicated. It is virtually impossible to remain anonymous when reporting events, because often only a few people had direct knowledge of the event. There is a culture among physicians to cover for each other, and many expect this as a professional courtesy. It takes enormous courage to question the aptitude of a colleague. Uncomfortable confrontations at staff meetings can be discouragement enough.

The situation for residents is even bleaker. While we are often the ones who work most intimately with attending physicians, and may be best positioned to notice unsafe practices, we face even more resistance in reporting problems. Our attendings hold huge power over us, from day-to-day work conditions to future employment prospects. Anonymity cannot be expected. Retaliation can be brutal and long-lasting.

Still, few brave (or foolish) residents become whistleblowers, exposing dangerous practices that could hurt the patients who trusted us with their lives. Perhaps there is some secondary gain involved, in the form of satisfaction from proving themselves right and their superiors wrong. But overwhelmingly, it is the sense of justice and compassion that drives them. Even under threat of job termination, we must take action to protect our patients from harm.

 The author is an anonymous medical resident.

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