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Monday Mar 27, 2017

What to Do When Experienced Colleague Is Wrong? Speak Up

Speaking up has never been a problem for me. In fact, I had a harder time learning when to keep my mouth shut.

However, there were times, especially just out of residency, when I was hesitant to question the opinion of a subspecialist or a more seasoned physician. For the young physician, there often is a sense that the more experienced physician's opinion carries more weight than ours does. And if our assessment of a situation is different, it must be inaccurate.

This lack of confidence does a disservice not only to us, but also to the patient and sometimes to the other physician, as well.

I am a simple family doctor. I did not attend Harvard or Yale. I did not do my residency at Johns Hopkins. I pull double duty as a specialist with a certification in sports medicine, but I did not obtain this from the Andrews Institute. I do, however, believe that I received excellent training, just as the physicians who attended those revered institutions did. All our mothers should be proud.

I'm not suggesting that I don't make mistakes; I make them all the time. We all do. What I would warn physicians, both young and old, against is what I will call "elder deference bias." When we are confronted with an alternate opinion, we often defer to the opinion of the more experienced or specialized physician. The problem with this approach is that sometimes those opinions are wrong.

For example, I sent an adult patient with a cough for a chest radiograph. As I was reviewing the study, I was relieved to see that there were no indications of pneumonia. However, what I did see was a 12-millimeter pulmonary nodule. I expected the radiology report to recommend a CT scan for further evaluation. It did not. In fact, the nodule was not even mentioned in the report. I reviewed the radiograph again and then called the radiologist and discussed it with him. Not only did he agree that the nodule did indeed bear mentioning and further workup, he thanked me for catching it. After all, if I had assumed it was of no importance because the radiologist did not mention it, and it turned out later to be malignancy, we both would be on the hook and the patient would be even worse off.

I think some physicians feel that questioning the opinion of an elder physician or subspecialist might somehow insult them. The same can be true of patients, and they may hesitate to question treatment plans. For example, a patient recently came to me for a second opinion on a diagnosis a subspecialist had made. He reported he was afraid to ask for one because he did not want to upset the subspecialist. I regularly encourage second opinions, especially for difficult decisions, because it will do one of two things: confirm my assessment (which only increases my patient's trust in me), or prevent a mistake and help me to learn. I told the patient that if any physician, including myself, was mad because he wanted a second opinion, then he needed a new physician.

One such patient came to me not long after I left residency. A young man had been chased by law enforcement (a story for another time) through wood chips while barefoot, earning himself several splinters in the sole. He was being treated for cellulitis by a more established family physician in the community -- one who had a reputation for having little tolerance for disagreement. He had already received one course of antibiotics with little improvement and was working on his second course. I did not agree with the second round of oral antibiotics, and an exam roused my suspicion of deeper infection. After a radiograph of the foot appeared normal, I ordered an MRI, which indicated deep abscess and osteomyelitis. The man underwent surgery and six weeks of IV antibiotics -- and was able to keep all his toes.

None of us is all-knowing or infallible. We all make mistakes. Though we may be young, relatively new to this profession and without subspecialty training, our opinions carry just as much weight as those of more experienced or subspecialized physicians. Let us keep in mind that our goal as physicians, no matter our level of expertise, is the same: to provide the best care for the patient.

It may be your opinion that saves the next patient, but only if you have the courage to speak up.

Peter Rippey, M.D., enjoys outpatient family and sports medicine practice in a hospital-owned clinic in South Carolina.

Posted at 04:04PM Mar 27, 2017 by Peter Rippey, M.D.

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