Witnessing Incompetent or Inappropriate Behavior

Instructor's Guide: Witnessing Incompetent or Inappropriate Behavior

Case Summary

A pediatric resident and a surgical resident are seeing a 4-month-old female. Both believe the child needs to have a catheterized urine specimen collected, but they have been unsuccessful at performing the procedure because the child has labial adhesions. The surgical resident grasps the labia and pulls them apart, leaving a raw, bleeding labial surface. When the pediatric resident asks her attending for advice, she is told to make no mention of the event in the chart and to say nothing to the family.

  • Has the behavior of the surgical resident resulted in harm to the patient?
  • Do you have an obligation to the family to notify them of this harm?
  • What is your obligation to make sure the surgical resident understands the implications of his behavior?
  • Does this need to be documented on the chart?
  • How do you handle the situation if your attending tells you to simply "walk away"?

Alternative Cases

  • A child who has clearly been mismanaged is transferred to your hospital. The parents of the child want to know what you think about the care they received from the other physician.
  • You are caring for a 10-year-old who has had a single seizure in the past, and who has been placed on Prozac and several other psychotropic medications for the seizure. She has no other medical problems and presents now with deteriorating school performance.
  • You are on staff at a hospital where surgical outcomes of cardiac procedures fall significantly below those of another institution across town. You have a 2-month-old with a cardiac defect that requires surgery. Do you refer him to the cardiac team at your hospital (as expected) or risk repercussions by referring him elsewhere?
  • A colleague (attending) shows up for work with alcohol on her breath and slurring her words. She resists any suggestion that she is impaired.
  • A physician colleague has been behaving erratically lately and confides in you that he has AIDS. He requests that you tell no one else.

Learning Objectives

After participating in this module, the student should be able to:

  1. Recognize that one has obligations to patients when harm has been witnessed
  2. Define the extent of a physician's duties to the patient and to the other parties involved when a colleague has acted incompetently or inappropriately
  3. List strategies for dealing with situations in which an authority figure makes a request that may be wrong or inappropriate
  4. Understand the implications of "whistleblowing" and the factors that should be considered before deciding to do so
  5. Develop strategies for informing another physician about concerns you may have regarding their management of a patient

Suggested Reading for Instructor

Bok S. Secrets: On the Ethics of Concealment and Revelation. New York: Random House (Vintage Books); 1983.

Council on Ethical and Judicial Affairs, American Medical Association. Disputes between medical supervisors and trainees. JAMA. 1994;272:1861-1865.

Dwyer J. Primum non tacere: an ethics of speaking up. Hastings Center Report. 1994; 24 (1):13-18.

Frader J. Referral back to an incompetent primary care provider. In: Iserson KV, Sanders AB, Mathieu D, eds., Ethics in Emergency Medicine. Second ed. Tucson, Arizona: Galen Press, Ltd.; 1995:276-278.

Knight JR, Palacios JN, Shannon M. Prevalence of alcohol problems among pediatric residents. Arch Pediatr Adolesc Med. 2000;154 (Jan):1181-1183.

Morreim H. Am I my brother's warden? Responding to the unethical or incompetent colleague. Hastings Center Report. 1993;23:19-27.

Weiner J, Snyder L. The impaired colleague. In: Snyder L, ed., Ethical Choices: Case Studies for Medical Practice. Philadelphia: American College of Physicians; 1996:79-84.

Shreves JG, Moss AH. Residents' ethical disagreements with attending physicians: an unrecognized problem. Acad Med. 1996;10:1103-1105.

White BD. The questionably impaired health care professional. In: Iserson KV, Sanders AB, Mathieu D, eds., Ethics in Emergency Medicine. Second ed. Tucson, Arizona: Galen Press, Ltd.; 1995:284-292.

Witnessing Incompetent or Inappropriate Behavior

1. Instructor's Guide 2. Student's Guide 3. Case Discussion

This instructor's guide was developed by Douglas S. Diekema, MD, MPH, director of education, Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Hospital.

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