Professionalism for residents
By: Michael C. Veronesi, MD, PhD, and Kate Hanneman, MD
Read the following scenarios on professionalism from the resident's perspective and test yourself by choosing the best answer to the provided prompts.
Dr. Res, an on-call radiology resident at an academic medical center, is interpreting a head CT study of a patient who presented with left-sided weakness when he notices an abnormal focus of high attenuation in the right side of the patient’s brain. Unsure if the abnormality represents blood or an artifact, Dr. Res pages the off-site attending neuroradiologist for help. After waiting 10 minutes, he tries to call the attending directly using the only phone number (for a cell phone) published in the department’s phone directory. Meanwhile, an emergency department (ED) physician who also noticed the abnormality requests a final interpretation from Dr. Res, knowing there is still time to give anticoagulant therapy for an acute nonhemorrhagic stroke if the finding does not represent blood. As Dr. Res waits for the attending’s return call, he interprets several other emergency on-call imaging studies in his work queue, including studies of a patient with acute aortic dissection and a patient with bowel perforation. Dr. Res spends the next 45 minutes diagnosing and managing these life-threatening cases, including conducting detailed discussions with ED physicians. About 1 hour after sending his initial page, Dr. Res finally receives a return call from the on-call neuroradiologist, who is very upset and yells at the resident for not calling him on his home phone, even though that number was not listed in the directory. Back in the ED, the window of time in which to administer emergent treatment of ischemic stroke with anticoagulant therapy has passed, and the ED physician blames Dr. Res for the delay.
Who should carry the ultimate responsibility in this scenario?
A) With or without input from the attending radiologist, Dr. Res is responsible as the resident on call and should have given the ED physician a final reading on whether or not there was acute intracranial hemorrhage on the head CT scan.
B) Dr. Res made the right decision to page the radiology attending who is on call and to work on the other emergent cases at the same time. However, Dr. Res is still ultimately responsible, since there is no set time limit for when an off-site radiology attending who is on call is obligated to answer his pager or phone.
C) The attending radiologist is ultimately responsible because a final reading was requested on an emergent imaging study, and he should have ensured his work availability at all times while on call.
Although medical care is often provided by resident physicians at academic medical centers, the attending physician is ultimately responsible for supervision and patient care. Therefore, answer C is correct.
This holds true in the setting of on-call coverage provided by radiology residents; the attending radiologist is ultimately responsible for supervising the radiology resident and should be readily available to the on-call resident for questions and consultation. Even though the radiology resident is often the primary provider of radiology care in the emergency setting, the resident remains a physician in training and thus requires appropriate and timely support. Therefore, answer A is incorrect.
In this scenario, the resident did the right thing by calling the on-call attending subspecialty radiologist when he was faced with a situation that was beyond his perceived level of expertise or comfort. In an age when PACS systems are ubiquitous, on-call attending radiologists are typically expected to respond to pages or calls within a reasonable amount of time, typically on the order of 5–10 minutes. Therefore, answer B is incorrect.
However, in the case of a prolonged lack of availability of a specific subspecialty radiologist, the resident should contact the backup on-call radiologist or administrative radiologist. Even though the emergency physician is responsible for the patient, it is not his job to ensure proper and prompt interpretation of an emergent imaging study at an institution where emergency services are being provided by the radiology department. Therefore, answer D is incorrect.
In the setting of emergency care of a patient, all physicians involved in that care assume responsibility for the patient’s current welfare. Therefore, all other health-related factors leading up to the patient’s emergent health needs are not reasons for the caring physician to abdicate clinical responsibility for the patient. Therefore, answer E is incorrect.
D) The ED physician is ultimately responsible for the patient and should take matters into his own hands if the radiology service cannot provide him with a timely report.
E) The patient is ultimately responsible, since she engaged in daily behaviors that promoted the development of stroke, including smoking for 30 years, eating a fat-laden diet, engaging in no exercise, and not seeking regular medical care. All physicians should accept the reality that patient care and patient outcomes are often beyond a physician’s control.
A) Yes; the resident was unprofessional, since he should have known ahead of time that this particular attending radiologist preferred to be called on his home phone.
B) Yes; the ED attending physician violated his professional obligations to the patient, since he deferred to radiology for the final reading on the head CT scan instead of treating the patient based on his own clinical assessment.
C) Yes; the attending radiologist violated his professional responsibility by failing to answer his pager and cell phone promptly while on call, thus failing to support the on-call resident during a critical time of need.
In academic radiology departments, the night call rotation for radiology residents serves several purposes. First and foremost, it provides emergent medical services for ill patients (1). The second purpose is to provide training and experience for trainees; this function is not trivial and serves an important role in providing sufficient clinical experience for the trainees, thereby allowing them to progressively develop autonomy during their residency. Finally, resident night call is necessary to grow the specialty and provide attending-level care to future patients. However, it is morally imperative that this secondary purpose remain subservient to the primary purpose of providing appropriate emergent services to patients in need (1). In this regard, it is important that on-call attending radiologists be consistently available for questions and consultations in order to support the radiology resident’s work in providing appropriate and timely care for patients. Therefore, answer C is correct.
The off-site covering radiologist should provide a working telephone number that is answered promptly. If an off-site covering radiologist is not available at a published landline, then he or she should use a cell phone or beeper to ensure continued availability. Therefore, answer A is incorrect. Closer supervision of medical trainees has been shown to lead to fewer errors, lower patient mortality, and improved quality of care (2). In this regard, direct supervisory involvement in patient care may be the most critical element of effective clinical supervision (3).
The tension between meeting the best interests of patients and the training needs of residents is an inherent part of the tripartite mission of academic medicine—in this case, a conflict between the clinical and educational missions. The perceived need to bolster the clinical mission has led to substantial demand by many academic medical centers to increase the availability of, and supervision by, on-site attending radiologists during the nighttime and weekend hours, including mandating 24-hour in-house coverage 7 days a week for all 365 days of the year. Such a change may enhance patient care and reduce errors, but it could also, in theory, stifle the development of resident autonomy and confidence on overnight call, where the resident might otherwise be faced with making important decisions with critical management implications. On the other hand, increased attending presence and availability could counter the “hidden curriculum” (4), “which substantially affects resident perceptions of supervision and may act as a barrier to requesting assistance, even when it is clearly necessary” (3).
Residents who are on call without in-house attending coverage may be hesitant to call an attending in the middle of the night, as they “do not want to appear incompetent” and may be concerned about offending those in power (5). In one study, residents reported tension “between wanting to be sure one is taking the correct action and wanting to know enough not to have to contact the attending” (5). Since on-call radiology residents are encouraged to report critical findings to the referring physician as quickly as possible, they may certainly provide preliminary reports that may lead to urgent action by the referring physician. However, they do not provide final interpretations and certainly should not report a “definite” radiologic finding about which they are not sure. Therefore, answer D is incorrect.
Despite increasing pressure to provide 24-hour attending coverage, many academic radiology practices still rely on residents to provide overnight preliminary reports (1). Depending on the program and culture, residents may be very hesitant to call an attending physician overnight or on weekends, even if they are uncertain about a study. When contacted, it is imperative that attending radiologists reply promptly and fully support the resident in providing timely and appropriate patient care. In this case, the failure to provide prompt radiologic interpretation in a clear and definitive fashion puts the emergency physician in a potentially untenable position, where he or she has to make an important clinical decision without sufficient confidence about the nature of the results of the head CT study. While the ED physician may choose to treat the patient according to his opinion of the imaging findings, the final interpretation of the radiologic study is not his responsibility. Therefore, answer B is incorrect.
Systems-related problems are often the cause of clinical errors. However, in this case, there were redundant processes in place to reach the off-site covering subspecialty radiologist. The resident attempted to contact the off-site attending radiologist by using both the pager system and the attending radiologist’s cell phone number. It is easy to understand how a sleeping individual might miss a beeping pager that is placed in a nightstand drawer or otherwise misplaced. Similarly, calls to cell phones may not be received for various reasons, both technical and personal. However, since the attending physician did, in fact, respond 1 hour later, it appears that the system in place did work and that use of the published phone number was not a primary reason for the delay in responding. Therefore, answer E is incorrect.
D) Yes; the resident violated his professional obligations, since he should have given the ED physician a final reading by himself and should not have relied on the on-call attending neuroradiologist.
E) No; professionalism was not violated in this situation, as this was simply a system-related problem related to a mistake in publication of a correct phone number.
A few days later, Dr. Res is in the reading room dictating a preliminary reading for a CT exam when he overhears two of the attendings talking in the corner. Dr. Tall asks Dr Short, “Did you see how resident Dr. Junior missed free air in the abdomen on a radiograph while on call the other night? She nearly killed that patient with her miss.” “I heard about the missed call,” said Dr. Short, “but I tend to give the resident the benefit of the doubt since she is in training after all, and we don’t truly know the circumstances of the events facing the resident while on call that night.” “What?” asks Dr. Tall. “How can you stick up for a resident who clearly failed to make a call that even a 1st-year medical student could make? That resident does not have much of a future as a radiologist!” Dr. Res cringes at hearing this criticism, since this resident is one of his good friends and is typically very accurate in her reads and conscientious when on call. Dr. Short replies, “I understand how you might feel, but your lack of support for the resident is not going to improve the matter in any way and could seriously jeopardize that resident’s confidence. This would not be good for the resident, the patient, or even the department.”
Is Dr. Tall within the boundaries of professionalism in expressing his opinion openly about this particular resident?
A) Yes, because not every attending physician can serve as an inspiring role model, and it is reasonable to expect some attendings to express critical and intimidating comments as a way to motivate residents.
B) Yes, because Dr. Tall can say whatever he pleases, since he is a full professor and assistant chair of the department.
C) No, because Dr. Tall is infringing on his obligation to uphold a professional environment, and he is ignoring the long-term negative impact of his words on residents’ morale and motivation.
The recent literature regarding clinically significant missed findings in preliminary radiology reports shows a very low “miss” rate for residents, between 0.5% and 2% (6,7). Radiology residents taking independent call steadily improve over their years of call-taking experience (7). When an error does occur, it is important that the resident is able to learn from the mistake, without shame or blame. In the Institute of Medicine’s 1999 report, “To Err Is Human,” the editors found that the majority of medical errors are not the result of a single individual’s reckless action. “More commonly,” the report states, “errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them” (8). The report notes that “when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error” (8). An attending physician who reprimands a resident in the middle of the night does a disservice to the patient care environment and ensures that the resident will agonize over whether to call this particular attending radiologist the next time. Therefore, answer C is correct.
Thus, it is essential that radiology residency programs promote a respectful culture of safety without finger-pointing or blame (9). While an attending physician has the right to voice his or her opinions, he or she should do so in private conversation away from the possible ears of trainees and should be careful to avoid gossip. Therefore, answers B and D are incorrect.
The attending should be conscious of how even subtle actions and words can have an enormous impact on the culture of a department and the professional environment, as well as the potential deleterious effect on residents’ morale. Therefore, answer A is incorrect.
Errors made during an on-call rotation should be regarded as learning opportunities, and residents should be supported throughout this important clinical activity, so that they are less likely to make the same error in the future. Ideally, the attending radiologist should provide the resident with an opportunity to review this case again within a relatively short period of time so that the resident can get constructive feedback. Therefore, answer E is incorrect. In so doing, the attending physician should be mindful of some basic tenets of adult learning, including the provision of a supportive learning environment where there is open dialog between the resident and the attending. In addition, the attending radiologist should share positive information with the resident before negative information and should provide feedback that is “specific, objective, consistent, and timely” (10).
D) Yes, because every attending physician is allowed the latitude to express his opinions about a particular resident’s performance, especially since this particular resident missed such an obvious life-threatening abnormality.
E) No, because attending physicians should not discuss missed cases until the time of residents’ performance reviews with the residency director.
A few weeks later, Dr. Res is reviewing an emergency CT scan of the abdomen and pelvis that was performed to rule out appendicitis in a febrile patient with right lower quadrant pain. Although the radiology resident does not observe significant distention of the appendix, he thinks that there is mild periappendiceal stranding and is worried that this finding might reflect an early sign of acute appendicitis. He goes to review the case with Dr. Abdo, who also happens to be the head of the division. Dr. Abdo spends a few minutes examining the study before declaring, “Normal. No evidence of appendicitis,” and then rushes off to an important meeting. Dr. Res tries to stammer out an explanation of the findings about which he is worried, but Dr. Abdo is already halfway out the door and brushes him off, replying, “It’s a negative study.” Dr. Res is still not convinced, so he decides to leave a description of “Possible periappendiceal stranding” in the body of the report, but he changes his conclusion to “No evidence of appendicitis.”
Did Dr. Res behave professionally in this scenario?
A) Yes; Dr. Res discovered a potentially important finding on a CT study, and as a resident physician, it is his right and responsibility to include this finding in the final report, even if the attending radiologist does not agree with him.
B) No; Dr. Res should have asked Dr. Abdo after his meeting to carefully review the possible periappendiceal stranding and should not have included a covert description of findings that Dr. Abdo explicitly considered normal.
Postgraduate trainees are not independent practitioners or specialists. They are pursuing an educational program and individual objectives toward independence in a graded fashion under the supervision of the training program and physicians. In the course of their clinical work, radiology residents are encouraged to perform preliminary interpretations of imaging studies, after which the residents can review them with the attending radiologist. Therefore, answer D is incorrect.
During this review process, residents often initially discover potentially positive findings that attending radiologists later correctly interpret as normal or an anatomic variant. However, on occasion, residents sometimes persist in believing that a given imaging finding is abnormal, whether correctly or incorrectly. In this case, more detailed discussion and information gathering are typically required to resolve this conflict. After this conflict is resolved, then a final report can be generated that reflects the opinion of both individuals. Therefore, answer A is incorrect.
Faulty communication may occur in the context of the relationship between a resident and an attending physician with whom the resident works. In one study, “residents’ concerns about offending those in power” (5), combined with the pervasive perception that those in power would not listen to them or hear their point of view, discouraged residents from “productively disagreeing when they had a different point of view” (5). Residents may be “concerned about appearing incompetent in front of those with more power” (5) and may be “hesitant to communicate information” that is “unfavorable or negative to themselves” (5). Therefore, answer E is incorrect.
In rare situations, it may be appropriate for two professional individuals to continue disagreement on a clinical issue. Most disagreements do not require the initiation of a formal conflict resolution process. Therefore, answer C is incorrect.
However, when a conflict or difference of opinion persists between an attending physician and a trainee, there should be a protocol in place to resolve disagreements. Mechanisms should exist to guarantee patient safety, particularly when a disagreement between a trainee and a clinical supervisor involves the appropriateness of patient care, and, in the mind of the trainee, when such disagreement places the patient's care in jeopardy. Ideally, a trainee and the attending physician or clinical supervisor should have a face-to-face discussion about such a concern. Finally, if this discussion does not resolve the issue, then the appropriate departmental policy should be followed, including consultation with a site coordinator, program director, and/or radiology chief or chair.
In this scenario, Dr. Res is in a very difficult position. His lack of confidence in Dr. Abdo’s interpretation may or may not be well founded. On the one hand, it may be quite reasonable for an experienced abdominal radiologist to make a definitive positive or negative diagnosis of appendicitis on a CT within a few moments. On the other hand, the attending radiologist may indeed have been distracted by thoughts of the upcoming meeting or have looked at the case too quickly. Moreover, an attending radiologist in a training program owes it to the trainee to encourage and discuss any questions that the resident might have about a case.
It would have been appropriate for Dr. Res to speak with Dr. Abdo in person immediately after the conclusion of his meeting to review the continuing concerns of Dr. Res in detail. This would have afforded an opportunity to facilitate learning by Dr. Res and to promote open communication and relationship building. Therefore, answer B is correct.
On the other hand, Dr. Res also risks questioning the attending’s competence, depending on how he approaches the discussion and on Dr. Abdo’s temperament. Dr. Abdo has already demonstrated that he might be “too busy” for such a discussion, and he might not be appropriately receptive to the resident’s questions. Thus, it takes some degree of courage for the resident to approach Dr. Abdo later in the day, and the ease of it depends on their preexisting relationship. While talking to Dr. Abdo later is clearly the optimal option, sometimes conditions are not ideal, and Dr. Res may also wish to seek consultation with a trusted co-resident or another attending in advance of the discussion with Dr. Abdo.
C) No; Dr. Res should have immediately gone to the chair of the department and reported Dr. Abdo for negligence and malpractice.
D) Yes; Dr. Res shouldn’t even bother looking at imaging studies or trying to formulate a differential diagnosis before reviewing them with the attending radiologist, because he will be told what to write into the radiology report anyway.
E) Yes; Dr. Res is just a resident, and residents should not confront attending radiologists about potentially discrepant findings on imaging studies.
At the start of one of his rotations, Dr. Res is approached by an attending radiologist, Dr. Publish, who asks him to write a review paper during the rotation. Dr. Publish is known to be an ambitious attending who has published extensively, mostly by recruiting residents and medical students to write papers for him. He frequently attempts to recruit trainees to write papers while he is explaining their residency rotation requirements, resulting in confusion regarding actual rotation responsibilities and expectations. Dr. Res is slightly overwhelmed but agrees to write the review paper, since he mistakenly believes it to be part of his rotation requirements. He works late at night over several weeks to complete the paper. One week after turning in the first manuscript draft to Dr. Publish, Dr. Res happens to be reading through his rotation requirements more closely and notices that while there is a requirement to make a PowerPoint presentation of a more advanced subject, there is no requirement to write a paper of the length and detail that was asked of him by Dr. Publish. On top of that, the attending radiologist responsible for collecting the PowerPoint presentation has asked him to turn in this assignment. He approaches Dr. Publish, who responds by saying, “Hmm … I was under the impression that you could do one or the other, but now that you’ve written the paper, why don’t we submit it for publication? You can be the first author, and I’ll be the senior author.” Dr. Res knows the paper will require much more work before it can be published, and he has not yet started working on the required PowerPoint presentation. Concerned that he might get a bad evaluation from Dr. Publish, he agrees to make the substantial revisions required to submit the paper for publication and also manages to complete his rotation presentation by working in every spare minute during the last week of his rotation.
Does Dr. Publish’s behavior constitute a violation of professionalism?
A) No; although the approach taken by Dr. Publish was underhanded, the fact that it will result in a publication will be a good thing for the resident in the long run. Therefore, this is not a professionalism issue.
B) Yes; Dr. Publish manipulated the resident by couching the request as a requirement for his rotation when, in fact, there was no such requirement. Dr. Publish should have clearly indicated that writing a paper was an optional addition to the rotation requirement of a PowerPoint presentation.
At certain institutions, publications are important for career advancement. It can be mutually beneficial for an attending radiologist to encourage and supervise residents in writing papers for publication. However, this may be problematic if the resident feels manipulated into writing a paper by the fear that not agreeing to do so might result in a poor rotation evaluation. A resident should never feel pressured to write a paper unwillingly if it is not actually a part of the residency training requirements. Therefore, answer B is the correct answer. The residency program should have clear guidelines, as outlined by the Accreditation Council for Graduate Medical Education (ACGME), about the requirements for publications. If there are any questions as to whether a request by an attending is appropriate or not, the resident should confirm the request with the program director.
The potential long-term benefit resulting from the publication for Dr. Res does not justify the actions of Dr. Publish. Therefore, answer A is incorrect.
Although residents often write manuscripts during the course of their residency training, the manner in which they are approached and motivated to complete this task is not inconsequential. Academic radiologists such as Dr. Publish have an obligation to mentor residents and students in a manner that is honest and free of manipulation. Therefore, answer C is not correct.
According to the ACGME Program Requirements for Graduate Medical Education in Diagnostic Radiology, “during their training, all residents must engage in a scholarly project under faculty supervision. … This may take the form of laboratory research, or clinical research, or the analysis of disease processes” (for example, a retrospective review), “imaging techniques, or practice management issues. … The results of such projects must be published or presented at institutional, local, regional, or national meetings” (11). The ACGME also indicates, “The program must specify how each project will be evaluated” (11). In each residency program, it should be made explicitly clear to residents what is expected in order to satisfy the requirement for engagement in a “scholarly project.” Therefore, answer D is incorrect.
C) No; it is not uncommon for an attending radiologist to ask a resident to write a paper. The manner in which Dr. Publish motivated the resident to write a paper in this scenario is inconsequential.
D) No; the resident should have known ahead of time what his requirements were on this particular clinical rotation. Since he agreed to write the paper, he is now obligated to submit it for publication.
A few months later, Dr. Res changes rotations and begins working for the first time with one of his 1st-year female co-residents, Dr. Nueva. After a few days, Dr. Nueva and Dr. Res are walking in the hall on the way to lecture. She asks in a quiet voice, “Is Dr. Chase normally a very friendly attending? He seems more friendly to me than others he interacts with.” Dr. Res gives it some thought and then says, “If it feels weird to you, then it probably is. Have you talked with the program director or an ombudsman about it?” “No way!” says Dr. Nueva, adding, “I’m just starting out as a 1st-year resident here, and the last thing I need is to accuse a long-standing faculty member of something as serious as that!” Over the course of the rotation, Dr. Res notices that Dr. Nueva appears more and more distracted at work and uses several sick days. When she returns to work, Dr. Res approaches her and asks if she is feeling okay and if her absence had anything to do with Dr. Chase. She looks around for a second, hesitates for a moment as if about to say something serious, and then turns back to him and states, “Oh, I’m fine now. I must have come down with a virus or something.There’s no need to worry about me.” And then she hurries off.
What should Dr. Res do in this situation?
A) Since Dr. Nueva has stated explicitly that she is fine, Dr. Res should respect her statement and go about his day. After all, these kinds of uncertainties are not uncommon, and since she is an adult, he should be confident that she can handle it on her own.
B) Dr. Res should confront Dr. Chase directly. By doing this, Dr. Res is assuming an important leadership responsibility and will be rewarded for his efforts by the residency administration.
C) Dr. Res should contact his program director or a designated ombudsman to express his concern about the possibility that Dr. Chase might be engaging in improper interactions with Dr. Nueva.
Sadly, sexual harassment has been reported in residency programs with alarming frequency. In a published study, a large percentage of both men (83%) and women (93%) experienced, observed, or heard about at least one incident of gender discrimination or sexual harassment during medical school (12). The most common forms of sexual harassment experienced by female residents included the telling of sexist jokes, compliments on body or figure, and flirtation (13). The majority of responding female residents indicated that the sexual harassment they experienced or witnessed was generated from a supervising physician (13). Less than a quarter of these residents reported it to a supervising physician, and none reported it to the sexual harassment officer (13). Residents indicated they were afraid to report sexual harassment because it would adversely affect their evaluations, and some believed that such reporting would not be kept confidential and might result in retribution or punishment (14).
In this scenario, Dr. Res has reason to believe that an inappropriate relationship or interaction has occurred between a resident and an attending radiologist. Given the potential seriousness of this interaction, it would not be appropriate for Dr. Res to go about his day and do nothing. Therefore, answer A is incorrect.
In general, sexual relationships between a faculty member and a resident are discouraged or prohibited in most teaching environments, since there is an inherent inequality of power. Residents should be made aware of the person designated as an ombudsman, to whom they can speak in confidence if there is any concern regarding harassment, whether or not it is proven. Both residents in this scenario face substantial risk. It would not be appropriate for Dr. Res to confront Dr. Chase directly, nor is it appropriate for Dr. Res to first discuss the case with other faculty members of the section. Therefore, answers B and D are both incorrect.
In this case, if Dr. Res were unable to convince Dr. Nueva to do so herself (and with him present if she wished), the safest approach for the concerned resident and for Dr. Nueva would be to first discuss the matter with an independent ombudsman prior to approaching anybody in the department. Therefore, answer C is the correct answer.
“All medical and educational facilities should have a written sexual harassment policy in place. The policy should be made known to all personnel and affirm that the facility will not tolerate sexual harassment, will promote an environment free of such harassment, and will take disciplinary action when such harassment is discovered. The policy should also include a definition of sexual harassment, preferably including examples of behavior that does or does not constitute sexual harassment” (14).