Friday, September 16, 2005

The Hierarchical Tug of War: Learning to be a “Man”
by Wendy Sue Swanson

Oct. 18, 2002 - This week's episode features a slight twist to a recurrent theme in the ER, a visit from a "frequent flyer." Frequent flyer is the derogatory, slang term used to describe patients who recurrently return to the ER for primary care issues, chronic disease manifestations, or drug-seeking behaviors. This term demonstrates a symptom of physician and nurse fatigue due to the taxing care required for these patients amidst the chaos of urgent care situations. Often, when frequent flyers fall critically ill, their presentation is undervalued. In essence, patients can set themselves up for a "never cry wolf" scenario. True manifestations of disease are masked by past behaviors that lacked clinical credibility. In this episode, the attending physician and consulting cardiologist fall into this trap leading to an unnecessary fatality.

We are introduced to an ethical dilemma from the vantage point of the medical student. Unique to medical students is their junior, subordinate role while caring for patients under residents and attending physicians. Medical students initially may approach repeat patients differently than the housestaff, as students are rarely familiar with the entirety of the patient's medical history. Students rarely form distaste for a patient prior to their history and examination until briefed by an intern or resident regarding the patient's reputation in the hospital. Furthermore, medical students are rarely fortunate enough to take care of the same patient twice throughout their training. In this episode, Mike has taken care of the patient four times prior to her presentation of reproducible chest pain. Fortunately, he remains compassionate and concerned for her care as he has spent considerable time and investment acquainting himself with her particular situation.

Medical students rotate through clinical settings at one-month intervals. Therefore, when Mike encounters Stella (the patient) in the ER, he is not in sync with the exhaustion and bias generated from her past care. When confronting her symptomatology, Mike instantly becomes concerned about the possibility of a symptomatic ischemia (early symptoms of a looming heart attack) and thus recommends precautions of oxygen, nitro paste, a cardiac monitor and pain medication. He suggests a cardiologist consult which after some persuasion, Carter, the attending finally grants him. The power struggle begins as Carter remains dubious of any legitimate condition for concern and Mike demands a diagnostic work-up. When the senior cardiologist recognizes the patient, he reminds Mike of her regular, unnecessary work-ups and suggests sending her home on over-the-counter pain meds. The cardiologist states she's been worked up nearly ten times with no clinical findings. Mike, the med student originally asserts his opinion and desire for monitoring her cardiac function. The cardiologist notices his crossing the line and snaps to Mike, "When you become an actual doctor, Mr. Galant, then you can make the diagnosis." Mike backs down.

Seemingly dramatic, these episodes of machismo and disinterest in medical student opinion are extremely commonplace in the academic setting. There is an assumption that as the underling, your clinical instinct is novice, naïve and generally time-consuming for the team. As a junior team member and unlicensed training-physician, you are obliged to follow the directions of the physicians who sign your orders. Rocking the boat is a rare occurrence, as dissention is unwanted by attending physicians. In an article discussing the "Ethics of Speaking Up," James Dwyer states that it is extremely difficult for medical students to speak their minds during challenging situations in the hospital.1 He finds that medical students have obligations to remain respectful to their superiors (it is assumed you will agree with their choices), and that speaking up may incur risks and repercussions in regards to your grades, evaluations and recommendations. Grades in medical school are largely subjective when students reach clinical rotations. Thus, destroying your reputation may indeed destroy your future career. It is well known that residency selection is rooted in performance during medical school. Camaraderie is the ethos of the hierarchical game on the wards while "fitting in" an essential skill in surviving the wards in medical school. Finding a role on the team is admirable on any service, but achieving it can become supreme in a student's mind.2 Students report that this type of thinking causes them to do things they might otherwise question farther along in their training.2

Upon retrospection, medical students often feel they have let themselves and their patients down due to the pressures to comply with the educational system. In the ER episode, Mike becomes angered and belligerent after Stella dies from a heart attack. As he finds the space to reflect, he regrets not having had the courage to fight for a cardiac monitor for his patient. Akin to many specialized training programs, medical students learn the definitions of their margins for error and the consequences for not demanding responses. In a survey of medical students from 6 different medical schools in the Philadelphia area, approximately 70% of the students reported feeling bad or guilty about misbehaviors, unethical circumstances witnessed or experienced in the hospital.3 Often, students comply with the demands of their superiors only to find on introspection their dissention and guilt for backing down.

Medical students have a set of ethical issues that are unique to their position in the hospital.3 These ethical issues diverge from the scenarios generally faced by physicians in daily practice. Many of the ethical dilemmas that medical students encounter during their training evolve out of the requests ordered from superiors and difficulty interpreting personal relationships with staff. These issues often mirror the hierarchy of medical education and reflect rank before embracing a student's clinical intuition. Studies have evaluated how medical students attitudes are changed throughout their training, but few have evaluated the ethical dilemmas unique to being a student on a team in the hospital.3 Each typical ethical dilemma denotes how medical students feel impinged upon by the restraints of their roles and the social structure of the hospital working environment. Furthermore, Feudtner, Christakis and Christakis found that a sizeable portion of medical students struggle with their ethical self-identities following medical school.3

In this episode, Mike is faced with an attending that differs in his opinion in regards to the severity of patient's clinical presentation. He starts out his shift confident and eager to advise those in need in his surroundings, but leaves the ER questioning his ethical fortitude and ability to confront and stage dissention to powerful superiors. Although he remains attached to his patient, he dismisses his eager advocacy. Medical students are often allowed to spend more time with patients than their interns, resident and attending physicians. Because of the extra time allowed to acquire history taking and physical exam skills, they often become more exposed to the emotional struggles of the patient and more enriched by the details of a patient's life. Students therefore gain unique positioning for patient advocacy. However, their goals for patient advocacy rarely fit into the team's need for efficiency.

Despite the difficulty, medical students have an obligation to advocate for their patients and voice concerns for patient care. Regardless of the social structure, it is just to fight for proper patient care. With growing concerns towards malpractice, students are required to contribute to a nationally recognized standard of care for their patients. Early legal cases involving medical students allowed for a lesser than expected standard than the standard designed for residents and attending physicians. However, since the 1970s, case law indicates a shifting of responsibility. Those introducing themselves as practitioners, including students, should be held to the "standard of conduct" of licensed professionals.4 Thus, it is not only students who hold this responsibility, but those in the supervising capacities, namely professors and teaching attendings. It is essential that academic teaching environments confront hierarchical battles. Ethical dilemmas arise from the chasms of uncertainty inherent in medical care. For the benefit of their patients, their staff relationships, and the ethical education and preservation of aspiring physicians, open communication is an understated requirement.

1. Dwyer J. Primun non tacere: an ethics of speaking up. Hastings Center Report 1994: Jan-Feb: 13-18

2.Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Academic Medicine 1993, April; 68(4): 249-254

3. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Academic Medicine 1994, August; 69(8): 670-679

4. Butters JM, Strope JL. Legal standards of conduct for students and residents: implications for health professions educators. Academic Medicine 1996, January; 71(6): 583-90

Posted: 2002-10-18

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