AMA Journal of Ethics^®

Case

Amber and many of the other residents in her internal medicine program have become increasingly concerned about Bill, also a resident in the program. Bill seems to have inadequate medical knowledge and poor clinical judgment. He has made numerous mistakes, including failing to continue home medications when patients are admitted and ordering medications with serious interactions with other medications in the patient's regimen. Some of these errors have resulted in injury to patients. In addition, Bill fails to properly supervise interns working under him, leaving them alone to care for acutely ill patients or to run resuscitations.

Amber and the other residents have gotten in the habit of checking Bill's orders and reviewing his patients' care. The interns working with Bill rely on other senior residents in the hospital for their supervision. The residents are all aware that Bill is a problem, but as a result of their efforts to protect the patients and the interns many of the attending physicians aren't aware of the problem. Amber discussed the problem with Sarah, a friend in another residency program.

"You and the other residents are making things worse. No one notices how bad this guy is because you cover up for him," Sarah tells her.

Amber replies, "We aren't covering up for him, we are just protecting the patients by making sure he doesn't hurt anyone."

"Well it ends up hiding the problem from the supervisors and protecting a bad resident," Sarah chides her.

The hospital administration has heard serious concerns from nurses and residents. Bill has passed all his rotations despite poor evaluations and frequent negative comments. Some of the attendings are aware that he doesn't perform well, but they are not aware of the scope of the problem. Most of them have observed the other residents compensating for Bill, and they think this is good teamwork and reflects well on the other residents—that they are personally committed to ensuring good patient care. Amber asks her advisor why attendings give some residents poor evaluations without failing them.

Her advisor responds, "The attendings don't want to fail a problem resident because of the hassle of justifying a failure and because they don't want to damage the resident's career. Also, the result is usually that the resident has to remediate the month, which means that any attending who fails a resident is likely to be condemned to another month on service with that resident. It is unintentional punishment for the evaluating physician."

The administration cannot take any action against Bill because he has no failing evaluations, and the incidents are not documented. Physicians and nurses both fear legal consequences for themselves and the hospital if they document the mistakes and problems. No one wants to get involved in challenging Bill and alleging his incompetence formally.

Without documentation or failing evaluations, the hospital cannot fire Bill. Recently, Amber and the other residents have begun discussing the fact that as a result Bill will be graduating soon and will be practicing independently. Amber asks her advisor, "Do the other residents and I have any duty in this situation? Do we have any basis for taking some action? I don't even know what I can do, even if I get involved. If I do get involved and everyone else refuses to back me up, it looks like I'm petty and vindictive, so nothing changes, but my career is hurt."

Commentary 1

While it is likely that every resident has observed opportunities for improvement in patient care, communication, and professionalism amongst their colleagues, examples of ongoing severe negligence or incompetence are fortunately rare. The case at hand represents this rare situation of incompetence and seeks to examine options for Amber, who observes what are perceived to be gross deficiencies in the performance of her colleague, Bill. While Amber may feel as though she has few options, in fact she has many.

First, Amber might consider discussing her concerns with Bill himself. It might be appropriate to initiate such a conversation by inquiring as to whether Bill had any personal problems (particularly outside of work) that might be affecting his performance. If Amber does not feel capable of initiating such a conversation, she might enlist the support of another resident whom she feels Bill would view as a friend. Unfortunately, such conversations are never comfortable, and most residents would find confronting a colleague directly overly challenging.

Another possibility for Amber is to meet with one of Bill's supervising attendings who might then meet with Bill. One point made in the case scenario is that an attending might refrain from failing a resident to avoid having to work with that same resident again when he or she remediates the rotation at a later date. While this might be a minor concern in smaller programs, in larger programs the chance of the same resident and attending being paired up again at a later date is remote and, in any case, supervising attendings have the responsibility to provide a fair evaluation which, on occasion, mandates assigning a failing grade.

Perhaps the most realistic option for Amber is that she meet with the chief resident (CR). If a number of residents have similar concerns, it might be particularly useful for them to meet with the chief resident as a group. It will be important during such a meeting that the residents provide specific examples of their concerns. While Amber might fear that she will be viewed as a complainer, the CR may have already heard complaints from other parties. The chief resident is thus in an ideal position to assess the scope of the issue and assume responsibility for confronting Bill and bringing the issue to the attention of the program director (PD). Amber should also feel free to go directly to her PD. She should definitely voice her concerns to either the chief resident or program director, given the seriousness of the situation. Residents should not assume that the chief resident and program director already know about problems. In addition, the CR or PD may need additional documentation and support for claims that Bill's performance needs attention.

Perhaps more compelling than discussing the various avenues for Amber to voice her concerns is the question of what duties the attendings, CRs, and PDs have upon hearing of Bill's deficiencies. Each of these individuals has the responsibility to hear the concerns, assess their significance, review them with Bill, and initiate an appropriate response. What is not an option is to ignore Amber's complaints.

Assessing the significance of Amber's complaints is the first and perhaps the most difficult step. Unless Amber and her colleagues can provide specific examples of Bill's deficiencies it will be impossible to assess their significance and respond meaningfully. Nonetheless, it is imperative that this occur.

While actually meeting with Bill is the next step for the PD, and understandably uncomfortable, the following suggestions may lead to an effective and less emotional discussion. First, the meeting must occur in a timely fashion; it is unfair to everyone involved, including Bill, to delay for any significant length of time. Second, it is quite useful to begin the conversation by asking how things are going overall. It often becomes immediately apparent that there are significant, previously unknown, problems affecting, if not explaining, Bill's performance. Third, be specific. It is not only unhelpful, it is also unfair to Bill, to bring up general comments. Next, hear Bill's side. At the least, hearing Bill's perception and understanding of Amber's concerns may prove helpful in identifying what the next step should be. Finally, define the next step. This may vary from simply asking Bill to consider the complaints and meet again at a later date, to placing Bill on probation, suspending Bill, or recommending specific counseling.

Afterwards, the importance of documenting the meeting cannot be overemphasized. This is best accomplished through a letter addressed to Bill, describing what was discussed and, most importantly, the expectations for Bill's future performance and any potential consequences.

Finally, PDs must assume responsibility for fostering an environment in which residents feel comfortable discussing issues of professionalism and competency. Otherwise residents such as Amber will never bring their concerns forward, patients will continue to be at risk, and society's view of medical professionalism will continue to erode.