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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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37. Physician Disagreements
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Given one well-trained medical practitioner of the highest type, they will do better work for a thousand people than ten specialists.
~ William James Mayo
Disputed Prescriptions
The Case of the Disagreeing Doctors
Dr. Anna Martinez had been working as an attending physician for many years and was well-respected by her colleagues and patients. She was known for her thoroughness and attention to detail when it came to patient care. One day, a new resident, Dr. Jack Lee, joined her team. Dr. Lee was fresh out of medical school and eager to learn from Dr. Martinez.
One afternoon, Dr. Martinez and Dr. Lee were reviewing a patient’s case. Dr. Martinez had ordered a certain medication for the patient, but Dr. Lee disagreed with her decision. He felt that a different medication would be more effective in treating the patient’s condition. Dr. Lee voiced his disagreement, but Dr. Martinez was firm in her decision and asked him to comply with her order.
Dr. Lee was frustrated by the situation and felt that he was being silenced by Dr. Martinez. He considered going against her orders and prescribing the medication he thought was better for the patient. However, he knew that doing so could potentially harm the patient and could also result in legal repercussions for both himself and Dr. Martinez.
Dr. Lee decided to follow proper protocol and sought out guidance from the hospital’s policy and procedures for dealing with disagreements. He brought the disagreement to the attention of Dr. Martinez’s superior, the department chair. The department chair listened to both sides and ultimately agreed with Dr. Martinez’s decision.
Dr. Lee learned an important lesson about the importance of respecting the attending physician’s ultimate responsibility for patient care and management. He also realized that following the proper process for dealing with disagreements is a professional obligation based on medical standards of care.
Months later, Dr. Martinez and Dr. Lee encountered another disagreement about a patient’s treatment plan. This time, Dr. Lee brought up his concerns to Dr. Martinez, and they had a productive discussion. They were able to come to a mutual understanding and agreement about the best course of action for the patient’s care.
Dr. Lee had learned the importance of open and honest communication between attending physicians and resident practitioners when dealing with patient management disagreements. He knew that he had a responsibility to seek out guidance from his superiors and adhere to medical standards of care. In the end, the patient’s care and well-being were the top priority, and Dr. Lee was proud to be a part of the team that helped the patient achieve the best possible outcome.
Abstract
The attending practitioner holds ultimate responsibility and is legally liable for the patient's care, while the resident is part of the interprofessional healthcare team under the attending’s supervision. The principles of patient autonomy, beneficicence, nonmaleficence, and justice are emphasized. The resident must follow institutional policies and procedures for dealing with disagreements and bring any disagreements to the attending’s attention. The medical record is not for debating disagreements, but for documenting patient management. If harm or error occurs, the resident must learn how to analyze and report it, while being honest and open with the patient in order to maximize the patient’s best interests. Legal liability laws strengthen the medical profession and the patient-practitioner relationship. Following proper process for dealing with disagreements is a professional obligation based on medical standards of care.
**
Think
[37:1] The attending practitioner has the ultimate responsibility for the treatment management of the patient. Therefore, if the attending disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management. The attending practitioner is legally liable for both the treatment the attending provides and the treatment that the attending directs.
[37:2] If the resident disagrees with the attending’s treatment management, it is never permissible to change the patient’s care without the attending’s approval. The resident is also legally liable for any patient treatment provided and is held to the same medical standards of care as the attending practitioner. If the resident believes the attending is in error, then the resident must bring it to the attending’s attention, discuss the disagreement and come to a mutual understanding and agreement. If there is an irreconcilable disagreement, then it is permissible to bring it to the attention of the attending’s superior such as the division head, department chair, or chief of services who have the institutional authority to intervene in the patient management and quality of care issues.
[37:3] The patient-practitioner relationship is between the attending practitioner and the patient, and the resident is part of the supportive interprofessional healthcare team under the attending practitioner’s supervision.
Assess
Patient: 1) Autonomy
[37:4] Patient autonomy (informed consent) must be maintained at the highest level. This means that when a resident is introduced, the resident must be identified as a member of the interprofessional team that the attending practitioner is supervising. Disagreements that the resident may have about patient management should be brought to the attending practitioner’s attention, who is legally responsible for the care and supervision of the patient. Failure to follow this standard procedure is considered an assault on the patient-practitioner relationship, as it will undermine the patient’s trust in the practitioner causing a reduction in patient willingness to provide informed consent.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[37:5] Nonmaleficence (do no harm) is a cardinal value for the medical profession. Nonmaleficence (do no harm) is generally the concern when a resident disagrees with the attending practitioner’s patient management.
[37:6] If the resident has such a disagreement, then:
1. the resident must follow the institutional policies and procedures for dealing with the disagreement,
2. the resident must seek out the attending practitioner for deliberation about the disagreement, and
3. the attending practitioner must carefully listen to and address any questions, concerns, and disagreements from the resident or others on the interprofessional treatment team.
[37:7] The medical record is not the location to debate disagreements in patient management. Instead, it is for documentation of patient management. Objective documentation of one’s impression and plan will adequately reflect other options within the differential diagnosis and serve as a contemporaneous record.
[37:8] The resident is not to blindly follow what is thought to be harmful patient orders; rather, the resident is being directed to immediately seek out consultation with the attending practitioner to make sure that,
- 1. the orders of the attending practitioner are harmful,
- 2. recognize that not following the attending practitioner’s orders may put the patient in harms-way, and
- 3. if the resident is correct, then the attending practitioner’s order will be changed and documented in the medical record.
[37:9] If harm or error has occurred, then the resident needs to learn how to analyze and report the error(s) and cooperate with the attending practitioner to communicate the harm or error(s) to the patient. Beneficence (do good) promotes this open and honest communication for maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities. Knowing one’s role and responsibility and the medical standards of care when dealing with patient management disagreements is essential.
Public Policy: 4) Justice
[37:10] Society has implemented collective legal liability for institutions, attending practitioners, and resident practitioners for assuring that its citizens do not get suboptimal medical care while students are being mentored into the medical profession. Institutions, attending practitioners, and residents are all legally culpable for any patient treatment that does not meet the the medical standards of care. These liability laws strengthen the medical profession and society’s perception of the medical profession as a patient-practitioner relationship.
Conclude
[37:11] The attending practitioner has the ultimate responsibility for patient care and management. It is not professionally accepted for the resident to discuss disagreements they might have with the attending practitioner with the patient. The attending practitioner has the patient-practitioner relationship, and that must always be supported and respected. Following the proper process for dealing with disagreements is a professional obligation based on the medical standards of care.
[37:12] In summary, the attending practitioner’s responsibility for patient care and management is paramount, and it is crucial that residents respect and support the patient-practitioner relationship. When disagreements occur, following the proper process and adhering to medical standards of care is a professional obligation. By doing so, residents and attending practitioners can work together to provide optimal care and maintain the integrity of the medical profession.
**
37. Review Questions
1. The attending practitioner has the ultimate responsibility for the treatment management of the patient.
2. If the attending practitioner disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management.
3. If the resident disagrees with the attending’s treatment management, it is never permissible to change the patient’s care without the attending practitioner’s approval.
4. The medical record is an excellent location to debate disagreements in patient management.
5. If harm or error has occurred, then the resident needs to learn how to analyze and report the error(s) and cooperate with the attending practitioner to communicate the harm or error(s) to the patient.
6. Institutions, attending practitioners, and residents are all legally culpable for any patient treatment that does not meet medical standards of care.
**
CORRECT! 🙂
[37:1] The attending practitioner has the ultimate responsibility for the treatment management of the patient. Therefore, if the attending disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management. The attending practitioner is legally liable for both the treatment the attending provides and the treatment that the attending directs.
Wrong 😕
[37:1] The attending practitioner has the ultimate responsibility for the treatment management of the patient. Therefore, if the attending disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management. The attending practitioner is legally liable for both the treatment the attending provides and the treatment that the attending directs.
CORRECT! 🙂
[37:1] The attending practitioner has the ultimate responsibility for the treatment management of the patient. Therefore, if the attending disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management. The attending practitioner is legally liable for both the treatment the attending provides and the treatment that the attending directs.
Wrong 😕
[37:1] The attending practitioner has the ultimate responsibility for the treatment management of the patient. Therefore, if the attending disagrees with a resident’s patient management, the resident must comply with the attending’s treatment management. The attending practitioner is legally liable for both the treatment the attending provides and the treatment that the attending directs.
CORRECT! 🙂
[37:2] If the resident disagrees with the attending’s treatment management, it is never permissible to change the patient’s care without the attending’s approval. The resident is also legally liable for any patient treatment provided and is held to the same standards of practice as the attending practitioner. If the resident believes the attending is in error, then the resident must bring it to the attending’s attention, discuss the disagreement and come to a mutual understanding and agreement. If there is an irreconcilable disagreement, then it is permissible to bring it to the attention of the attending’s superior such as the division head, department chair, or chief of services who have the institutional authority to intervene in the patient management and quality of care issues.
Wrong 😕
[37:2] If the resident disagrees with the attending’s treatment management, it is never permissible to change the patient’s care without the attending’s approval. The resident is also legally liable for any patient treatment provided and is held to the same standards of practice as the attending practitioner. If the resident believes the attending is in error, then the resident must bring it to the attending’s attention, discuss the disagreement and come to a mutual understanding and agreement. If there is an irreconcilable disagreement, then it is permissible to bring it to the attention of the attending’s superior such as the division head, department chair, or chief of services who have the institutional authority to intervene in the patient management and quality of care issues.
Wrong 😕
[37:7] The medical record is not the location to debate disagreements in patient management. Instead, it is for documentation of patient management. Objective documentation of one’s impression and plan will adequately reflect other options within the differential diagnosis and serve as a contemporaneous record.
CORRECT! 🙂
[37:7] The medical record is not the location to debate disagreements in patient management. Instead, it is for documentation of patient management. Objective documentation of one’s impression and plan will adequately reflect other options within the differential diagnosis and serve as a contemporaneous record.
CORRECT! 🙂
[37:9] If harm or error has occurred, then the resident needs to learn how to analyze and report the error(s) and cooperate with the attending practitioner to communicate the harm or error(s) to the patient. Beneficence (do good) promotes this open and honest communication for maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities. Knowing one’s role and responsibility and the medical standards of care when dealing with patient management disagreements is essential.
Wrong 😕
[37:9] If harm or error has occurred, then the resident needs to learn how to analyze and report the error(s) and cooperate with the attending practitioner to communicate the harm or error(s) to the patient. Beneficence (do good) promotes this open and honest communication for maximizing the patient’s best interests as determined by the patient’s reasonable goals, values, and priorities. Knowing one’s role and responsibility and the medical standards of care when dealing with patient management disagreements is essential.
CORRECT! 🙂
[37:10] Society has implemented collective legal liability for institutions, attending practitioners, and resident practitioners for assuring that its citizens do not get suboptimal medical care while students are being mentored into the medical profession. Institutions, attending practitioners, and residents are all legally culpable for any patient treatment that does not meet the medical standards of care. These liability laws strengthen the medical profession and society’s perception of the medical profession as a patient-practitioner relationship.
Wrong 😕
[37:10] Society has implemented collective legal liability for institutions, attending practitioners, and resident practitioners for assuring that its citizens do not get suboptimal medical care while students are being mentored into the medical profession. Institutions, attending practitioners, and residents are all legally culpable for any patient treatment that does not meet the medical standards of care. These liability laws strengthen the medical profession and society’s perception of the medical profession as a patient-practitioner relationship.
37. Clinical Vignettes
1. Mr. Nathanael Morris, a 68-year-old retired accountant, is admitted to the hospital with chest pain and shortness of breath. The resident, assesses the patient and orders a chest x-ray, electrocardiogram, and blood work. The attending practitioner, reviews the results and disagrees with the resident’s diagnosis and treatment plan, believing that Mr. Morris is having a heart attack and requires urgent intervention. The resident disagrees, stating that the presentation is more consistent with pneumonia and that antibiotics should be initiated. The attending instructs the resident to transfer care of Mr. Morris to another resident and proceeds to intervene directly, ordering the necessary cardiac interventions. The resident is left feeling unsupported and frustrated. Which is the appropriate course of action for the resident to take in this situation?
2. Ms. Zoe Reynolds is a 65-year-old retired librarian who presents with a history of recurrent pneumonia, worsening cough, and shortness of breath. A chest X-ray shows bilateral infiltrates and she is admitted to the hospital with a diagnosis of community-acquired pneumonia. During her hospital stay, a resident practitioner and the attending practitioner disagree on the choice of antibiotics to treat Ms. Reynolds's pneumonia. The resident suggests a broad-spectrum antibiotic, while the attending recommends a narrow-spectrum antibiotic. The resident believes that the attending's recommendation is inadequate, and they are concerned that the patient's pneumonia may worsen. The resident decides to start the broad-spectrum antibiotic without the attending's approval.
3. Mr. John Smith is a 50-year-old retired construction worker who presents with abdominal pain and diarrhea for the past week. Upon evaluation, the resident suspects the patient may have inflammatory bowel disease (IBD), but the attending practitioner, disagrees and suggests that the patient's symptoms may be due to an infectious cause. The resident has reviewed the patient's medical history and completed a physical examination, but the attending wants additional tests to be conducted before making a diagnosis. The resident feels that waiting for additional tests may delay the patient's diagnosis and treatment, which may lead to worsening of the patient's symptoms. What should the resident do?
4. Ms. Abigail Davidson is a 60-year-old retired teacher who presents to the emergency department with acute onset chest pain. After a thorough workup, the attending practitioner diagnoses Ms. Davidson with a non-ST elevation myocardial infarction (NSTEMI) and recommends starting her on aspirin and heparin therapy. The resident disagrees with the attending practitioner's choice of anticoagulant and prefers to start Ms. Davidson on a direct oral anticoagulant (DOAC) instead.
5. Mr. Theodore Johnson, a 65-year-old retired mechanic, presents to the clinic with a three-day history of worsening chest pain that is non-radiating and associated with shortness of breath. After conducting a thorough physical examination, the resident suspects a diagnosis of unstable angina, and orders an electrocardiogram (ECG) and cardiac biomarkers. The attending practitioner reviews the ECG and cardiac biomarkers and disagrees with the resident's diagnosis, stating that Mr. Johnson's symptoms are more consistent with gastroesophageal reflux disease (GERD) and recommends treatment with antacids. The resident disagrees with the attending's diagnosis, stating that Mr. Johnson's presentation is not consistent with GERD, and insists on further cardiac workup. What should the resident do in this situation?
CORRECT! 🙂
Explanation: As stated in [37:2], the attending practitioner has the ultimate responsibility for patient care and treatment management, and the resident must comply with the attending's directives. In situations where the resident disagrees with the attending's plan, the resident must bring it to the attending's attention and seek to come to a mutual understanding and agreement. If there is an irreconcilable disagreement, it is permissible to bring it to the attention of the attending's superior, as outlined in [37:2]. It is not appropriate to confront the attending in front of the patient or nursing staff, as this undermines the patient-practitioner relationship and can lead to a loss of trust from the patient. Additionally, it is not appropriate to continue to follow a treatment plan that the attending has explicitly disagreed with. The resident has a duty to act in the patient's best interest and support the attending practitioner's ultimate responsibility for patient care, as emphasized throughout the Assess section.
Wrong 😕
Explanation: As stated in [37:2], the attending practitioner has the ultimate responsibility for patient care and treatment management, and the resident must comply with the attending's directives. In situations where the resident disagrees with the attending's plan, the resident must bring it to the attending's attention and seek to come to a mutual understanding and agreement. If there is an irreconcilable disagreement, it is permissible to bring it to the attention of the attending's superior, as outlined in [37:2]. It is not appropriate to confront the attending in front of the patient or nursing staff, as this undermines the patient-practitioner relationship and can lead to a loss of trust from the patient. Additionally, it is not appropriate to continue to follow a treatment plan that the attending has explicitly disagreed with. The resident has a duty to act in the patient's best interest and support the attending practitioner's ultimate responsibility for patient care, as emphasized throughout the Assess section.
CORRECT! 🙂
Explanation: The attending practitioner holds the ultimate responsibility for the patient's care, and the resident must follow the attending's treatment management [37:1-2]. Disagreements should be brought to the attending's attention, and the medical record is not for debating disagreements [37:3, 37:7]. In this case, the resident should follow the attending's recommended treatment. The patient-practitioner relationship is between the attending practitioner and the patient, and the resident is part of the supportive interprofessional healthcare team under the attending practitioner's supervision [37:3]. The other options are incorrect because it is never permissible to change the patient's care without the attending practitioner's approval [37:2], bringing up the disagreement with the patient would be a breach of the patient-practitioner relationship and would not be in the patient's best interest [37:4], and escalating the disagreement to a higher authority should only be done if the disagreement cannot be resolved between the attending and resident [37:2].
Wrong 😕
Explanation: The attending practitioner holds the ultimate responsibility for the patient's care, and the resident must follow the attending's treatment management [37:1-2]. Disagreements should be brought to the attending's attention, and the medical record is not for debating disagreements [37:3, 37:7]. In this case, the resident should follow the attending's recommended treatment. The patient-practitioner relationship is between the attending practitioner and the patient, and the resident is part of the supportive interprofessional healthcare team under the attending practitioner's supervision [37:3]. The other options are incorrect because it is never permissible to change the patient's care without the attending practitioner's approval [37:2], bringing up the disagreement with the patient would be a breach of the patient-practitioner relationship and would not be in the patient's best interest [37:4], and escalating the disagreement to a higher authority should only be done if the disagreement cannot be resolved between the attending and resident [37:2].
CORRECT! 🙂
Explanation: The resident's responsibility is to follow the institutional policies and procedures for dealing with disagreements with the attending practitioner [37:2]. It is not permissible to change the patient's treatment plan without the attending's approval, as both the attending practitioner and the resident are legally liable for the patient's care [37:2]. It is not appropriate for the resident to discuss their clinical suspicion with the patient or suggest a second opinion, as this undermines the patient-practitioner relationship and may reduce the patient's willingness to provide informed consent [37:4]. The medical record is not the place for documenting disagreements [37:7], as it is for documenting patient management. Bringing the disagreement to the attention of the attending and following institutional policies and procedures is the best course of action, as it promotes open and honest communication, benefits the patient's best interests, and strengthens the patient-practitioner relationship [37:3, 37:6, 37:9, 37:11].
Wrong 😕
Explanation: The resident's responsibility is to follow the institutional policies and procedures for dealing with disagreements with the attending practitioner [37:2]. It is not permissible to change the patient's treatment plan without the attending's approval, as both the attending practitioner and the resident are legally liable for the patient's care [37:2]. It is not appropriate for the resident to discuss their clinical suspicion with the patient or suggest a second opinion, as this undermines the patient-practitioner relationship and may reduce the patient's willingness to provide informed consent [37:4]. The medical record is not the place for documenting disagreements [37:7], as it is for documenting patient management. Bringing the disagreement to the attention of the attending and following institutional policies and procedures is the best course of action, as it promotes open and honest communication, benefits the patient's best interests, and strengthens the patient-practitioner relationship [37:3, 37:6, 37:9, 37:11].
Wrong 😕
Explanation: According to paragraph [37:2], the attending practitioner has ultimate responsibility for the patient's care and is legally liable for the treatment provided. Therefore, if the resident disagrees with the attending practitioner's treatment management, the resident must comply with the attending practitioner's recommendations. Additionally, paragraph [37:7] states that the medical record is not the location to debate disagreements in patient management, and objective documentation of one's impression and plan will adequately reflect other options within the differential diagnosis and serve as a contemporaneous record. Furthermore, as mentioned in paragraph [37:4], maintaining patient autonomy (informed consent) at the highest level is essential, and it is not appropriate for the resident to discuss disagreements with the patient. Finally, paragraph [37:5] emphasizes the importance of nonmaleficence (do no harm), and the resident must prioritize the patient's best interests by following the attending practitioner's recommendation.
CORRECT! 🙂
Explanation: According to paragraph [37:2], the attending practitioner has ultimate responsibility for the patient's care and is legally liable for the treatment provided. Therefore, if the resident disagrees with the attending practitioner's treatment management, the resident must comply with the attending practitioner's recommendations. Additionally, paragraph [37:7] states that the medical record is not the location to debate disagreements in patient management, and objective documentation of one's impression and plan will adequately reflect other options within the differential diagnosis and serve as a contemporaneous record. Furthermore, as mentioned in paragraph [37:4], maintaining patient autonomy (informed consent) at the highest level is essential, and it is not appropriate for the resident to discuss disagreements with the patient. Finally, paragraph [37:5] emphasizes the importance of nonmaleficence (do no harm), and the resident must prioritize the patient's best interests by following the attending practitioner's recommendation.
CORRECT! 🙂
Explanation: The attending practitioner holds the ultimate responsibility for the patient's care and management, and the resident is part of the interprofessional healthcare team under the attending's supervision [37:1-2]. If the resident disagrees with the attending's diagnosis, they should bring it to the attending's attention and come to a mutual understanding and agreement [37:2]. In this case, the resident should discuss their concerns and present the reasoning behind their diagnosis to the attending [37:6]. The medical record is not the location to debate disagreements in patient management, and objective documentation of one's impression and plan will adequately reflect other options within the differential diagnosis [37:7]. Following the proper process for dealing with disagreements is a professional obligation based on the medical standards of care [37:11].
Wrong 😕
Explanation: The attending practitioner holds the ultimate responsibility for the patient's care and management, and the resident is part of the interprofessional healthcare team under the attending's supervision [37:1-2]. If the resident disagrees with the attending's diagnosis, they should bring it to the attending's attention and come to a mutual understanding and agreement [37:2]. In this case, the resident should discuss their concerns and present the reasoning behind their diagnosis to the attending [37:6]. The medical record is not the location to debate disagreements in patient management, and objective documentation of one's impression and plan will adequately reflect other options within the differential diagnosis [37:7]. Following the proper process for dealing with disagreements is a professional obligation based on the medical standards of care [37:11].
**
37. Reflection Vignettes
1. Dr. Samantha Lee is a 28-year-old first-year resident who is currently working in the internal medicine department. Dr. Lee is treating a patient with severe gastrointestinal issues, and the attending practitioner has suggested a treatment plan that Dr. Lee disagrees with. The attending has recommended surgery, but Dr. Lee thinks that a more conservative approach would be appropriate. Dr. Lee is considering discussing the disagreement with the patient to see if they can also support a more conservative approach and then approach the attending together. This approach is highly unethical and unprofessional for several reasons. Firstly, discussing a disagreement with a patient undermines the trust and confidence the patient has in the attending practitioner and the medical team. Secondly, the resident does not have the necessary knowledge or experience to make independent medical decisions and should not be seeking support from the patient to challenge the attending's treatment plan. Thirdly, discussing a disagreement with a patient can potentially create confusion and conflict in the patient's mind, leading to unnecessary stress and anxiety. Finally, it is important for all members of the medical team to maintain a united front and work collaboratively towards the best outcome for the patient. Seeking support from the patient to challenge the attending's treatment plan undermines this collaborative approach and could potentially harm the patient.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
Dr. Sarah Kim is a 28-year-old resident in her second year of training in pediatrics. During rounds, Dr. Kim presents a treatment plan for a young patient with a rare genetic condition, which includes a specific medication regimen. However, the attending practitioner disagrees with the plan and suggests a different approach to treatment. Despite several discussions and attempts to compromise, Dr. Kim and the attending are unable to reach a consensus on the best course of action for the patient. In the end, Dr. Kim must comply with the attending practitioner as they are the ultimate decision-maker for the patient's care plan. The attending practitioner is responsible for the overall management of the patient's care, and it is their responsibility to ensure that the patient receives the best possible care. While it is important for residents to voice their concerns and opinions about patient care, ultimately, they must defer to the attending practitioner's judgment. This is especially important when there are irreconcilable differences between the resident and the attending, as patient care must not be compromised due to disagreements among the healthcare team.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
