Residents follow doctors' orders—even when they're wrong

'That husband lost his wife and that child lost her mother,' because I didn’t speak up, former resident says

Medical residents often fail to correct their superiors—even if they worry that the doctor is making a mistake—and that is putting patients at risk, a new study in the Canadian Journal of Anesthesia finds.

Dylan Bould, an anesthesiologist at Children’s Hospital of Eastern Ontario, helped spearhead the study after his own difficult experience during residency: Bould failed to divulge his reservations about the dosage of a drug his attending physician gave to a patient who recently gave birth. That patient later suffered cardiac arrest and died.

"I felt like I'd be making a fool of myself to speak up," but as a result of keeping quiet, "that husband lost his wife and that child lost her mother," Bould told the National Post.

For the study, researchers recruited 49 medical residents at the University of Ottawa and Queen's University and evaluated their responses when a doctor (played by an actor) asked them to administer blood to an adult patient who was a Jehovah's Witness—and against the patient's own religious wishes.

According to the study, none of the residents questioned the doctor's orders, despite the fact that they were unethical.

When the researchers asked the participants why they had agreed to administer the blood, many expressed the need to keep their heads "below the parapet" and believed that if a mistake was made, the legal and regulatory ramifications would apply only to the physician and not the residents.

In addition, some residents noted that speaking out against a superior could cause them trouble in the future and described a culture of fear and intimidation. One participant described his first day of residency, when he compiled what he thought were appropriate medications for a patient: "My staff anesthesiologist came into the OR and asked if those were my drugs. He proceeded to throw them in the garbage and didn't talk to me until after lunch. That was my first day."

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Other residents described similar incidents. One said, "I think [the physicians] pride themselves on sort of abusing junior residents," while another added, "You learn through shock and trauma so when you're yelled at, you never forget."

Residents also described comparable interactions with nurses. "Nurses love that last little kick at the can before you graduate [and] the second your... [doctor] leaves the room...they're just on you," attested one participant.

Bould says the study is important because it pulls back the curtain on the longstanding physician hierarchy and culture of blame that keeps more junior employees from speaking up. "When it's put on paper in writing … it does really make you sit up and pay attention," adds Susan O'Leary, president of the Canadian Anesthesiology Society.

The 'dangers' of working in health care: Abuse, bullying

Patient safety experts say health care should become more like the aviation industry, which encourages even the most junior-level staffers to report safety problems—and Bould agrees.

"Historically, there has been a lot of bad behavior in operating rooms, when people who have somebody's life in their hands on a daily basis get used to seeing themselves as very, very important," he concludes, "and perhaps sometimes kind of abusing that importance" (Blackwell, National Post, 3/29).

The takeaway: A culture of intimidation and bullying in the OR has prompted some residents to avoid speaking up—even if they believe their superior is making a mistake—and a new study finds that this intrinsic hierarchy could be harming patients.

Throwing 'invisible scalpels': A different take on disruptive physician behavior

Ask anyone at your organization, and they’ll tell you that throwing a scalpel in the OR is disruptive behavior. But what about talking down to a nurse? Or refusing to answer pages?

These behaviors are less extreme, but they’re much more common and often overlooked.

Hear from our experts on how to curb disruptive behavior at your organization.  Then take a closer look at our leadership development tools or craft a customized program from our library of 40+ workshops.


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