Disagreeing With Attendings: A Sticky Situation

“Uh…. can I run something by you?” My voice hesitated as I spoke into the phone to my attending, although I hoped I didn’t sound as unconfident as I felt. It was the inevitable late Saturday night admission. I had signed up for a moonlighting shift at our community hospital’s intensive care unit, hoping that it would be quiet enough for me to “catch up” on my delinquent bills and the research proposal I had been procrastinating on for weeks.

Alas, my patient (we’ll call him Mr. Smith) had a different plan for my evening. From the emergency department (ED), he was billed as “an AS patient with sepsis and stable BPs coming to the MICU for close monitoring and early goal-directed therapy.” Sounded relatively straightforward. But, when I saw him, something inside me told me that it was anything but. His BP while awake was in the low 80s and dipped into the low 70s when he fell asleep. “Well, whatever you do, don’t let him fall asleep,” I joked with the nurses to try to cover up the unavoidable uneasy feeling that was mounting inside.

Learning to Trust Your Instincts

From the surface, he was exactly as billed. All organs were being perfused by objective measures: he was mentating, his BP had been stable for the past 1 to 2 hours and he was making urine. Then, why did I feel so uncomfortable? Well, I think it was a “blink” response—something just didn’t feel right about monitoring” him in a small MICU in a community hospital. (As an aside: For those of you who haven’t read Blink by Malcolm Gladwell, I highly recommend it. A close friend recently bought me a copy and
it has made me trust my instincts more than I ever did before.)

Once I started digging into Mr. Smith’s records, I nearly fell out of my chair when I saw that his last TTE had a peak pressure gradient of 143 mm Hg. I ran to our doctor’s workroom to look at the “record labs” sheet posted on the wall by the interns (where the record values for labs and tests were recorded). I found “peak AS pressure gradient: 103 mm Hg” listed directly under “pH = 6.88.” The knot in my stomach grew bigger. The rest of his labs were notable for a rising troponin (dismissed by the ED as a “troponin leak” and false-positive as result of the ultrasensitive assay). I became more and more convinced that it might be a good to transfer him to Brigham and Women’s Hospital, where he could be admitted to the CCU, with a pulmonary artery catheter and a cath lab would be available in the event that he needed an urgent valvuloplasty.

I called the MICU attending, who sleepily told me to page the cardiologist on call and do whatever he or she said. I called, introduced myself as a future cardiology fellow, and tried, unsuccessfully, to impress upon him how tenuous Mr. Smith’s situation was. Although he listened carefully, he was somewhat dismissive and said, “As long as he is stable, I don’t see the need for the transfer!” and hung up before I got in another word.

Should You Speak Up or Shut Up?

This situation got me thinking—what should we do when we disagree with our attendings’ decisions? Within medicine, there is an inherent hierarchy, designed to transition us gently into our roles as blossoming physicians, and to create a system of checks and balances while we are learning in order to protect our patients. But, as we get farther and farther into our training, we begin to become experienced ourselves and when, if ever, does it become okay for us to “override” the decision made by an attending, especially if we think we are acting in the patient’s best interest? After all, I was there, looking at Mr. Smith, whereas the on-call cardiology attending wasn’t. Shouldn’t my instinct and experience count for something?

As cardiology fellows, this becomes especially relevant to us when we are interacting with attending physicians in other specialties. For example, when we are called to the emergency department for a “code STEMI” and we decide that it isn’t a real STEMI worth activating the lab for, contrary to the ED attending’s decision, we can always reach for the “my attending agrees with me” as our get-out-of-jail-free card to stand up to the ED attending. But, when your own attending doesn’t agree with you, speaking up is incredibly challenging.

This has become more palpable to me over the past few years. As I interact with senior cardiologists,
I realize that many of them haven’t chosen to recertify for their medical boards. On the other hand, I am fresh from poring over the MKSAP books and my knowledge of internal medicine is much more current and contemporary then theirs. So, I feel completely confident speaking up or challenging my attending when he/she suggests a management plan for medical issues with which I don’t agree. But, with cardiology, it is different since I, just embarking on my career as a cardiologist, feel uncomfortable questioning the decision of someone who may have seen patients for more years than I have been alive.

An Obligation to Our Patients and Ourselves

Yet, this incident makes me realize that it is critical for us to speak up if we disagree with a patient’s management, even if it is a senior attending. This is an obligation we have—both to ourselves and to our patients. And, if we are the eyes and ears “in the trenches,” sometimes our decisions on the battlefield count more than that of some war general, distant from the site of action—a fundamental teaching in warfare training. In addition, medicine should be a collaborative team sport, in which each of us contributes to joint decision making in order to give our patients the best care possible.

As we come into our roles as cardiologists, there are a lot of things we don’t know and we will no doubt be humbled at some point by a bad decision we make. The fact remains that medicine is an evolving field and there is a tremendous amount of learning and growth that lies ahead for all of us, not just as fellows but as junior attendings as well. But, we have to trust our instincts and feel assured that our experiences thus far have served us well. And, our attendings, most of who view us as junior colleagues, will admire our gumption.

I called the cardiologist back 30 minutes later and insisted that I felt very uncomfortable with his decision. He came in to assess the patient, agreed with my decision, and we initiated a transfer. After everything, Mr. Smith indeed came out of his septic shock uneventfully. But, I had the best post-call sleep ever knowing that I stood behind my instincts and had given him (and his heart!) the best chance they could get.

Keywords: Shock, Septic, Instinct, Intensive Care Units, Stomach, Books, Decision Making, Hospitals, Community, Sports, Emergency Service, Hospital, Pulmonary Artery, Research Design, Emotions, Hydrogen-Ion Concentration, Internal Medicine, Troponin

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