24The Chief Resident’s Dilemma

(1)

24

The Chief Resident’s Dilemma

Stephen Morgan

Medical residents are neither students nor employees; hence the conventions that exist in the normal business world do not always apply. Residency is often thought of as being more like indentured servitude than a true learning experience; things are often done “because the attending physician said so.” With that in mind, the following situ- ation is taken from my tenure as chief resident of pediatrics.

The Conﬂict

As chief resident, I was often called on to intervene, and hopefully resolve, interper- sonal conﬂicts between medical residents and interns. However, sometimes conﬂicts involve patients as well. One situation involved a relative of a child who was admitted for dehydration.

Things seemed to be going smoothly for the resident team taking care of the child until the results of admission laboratory studies indicated that he was more metabol- ically unstable than anticipated. The team responded to this by adjusting the rehydra- tion regimen and subsequently resampling the child’s blood to see if the new regimen was helping. Since the child was significantly dehydrated, venipuncture was difficult, requiring multiple attempts. This upset the child’s family significantly, as they did not understand the need for so many blood tests. After some discussion, the resident team arrived at a compromise to hold off on further blood tests for the time being and watch the child’s progress through observation only.

The following morning the primary care attending physician came in for rounds and reviewed the results from the previous day. She was not happy with the agreement with the family and insisted that the blood test be repeated again immediately. She spoke brieﬂy to the mother and left it to the resident team to perform the procedure. The child’s mother then called a close relative for advice. This relative soon came storming into the unit, threatening the resident team and almost striking one of the medical interns. She claimed that they were experimenting with her nephew and persecuting them because of their race. The resident team called the teaching attending physician, who was unable to calm the aunt down. He recommended that the resident team contact child protective services and have hospital security forcibly remove the aunt.

It was at this point that I became aware of the events and offered assistance.

229 LTF24 10/11/2004 9:14 AM Page 229

(2)

The Resident Team

This resident team is comprised of six members: two interns, one junior resident, one senior resident, and two medical students. In addition, there is a teaching attending physician who oversees the workings of the unit and educates the residents. Last, each patient admitted to the ward has a primary care physician who manages the care of his or her patients through the resident team.

• The intern, a physician in his or her first year of pediatric specialty training, is the workforce of the team. The intern is expected to be the primary caregiver for every patient on the ward. He or she writes daily progress notes in each of the patient’s medical charts and performs the necessary procedures for each patient. Because the workload is significant, this is a very stressful role. There were two interns on the unit at the time of the conflict.

• The next member of the team is the junior resident. This person is in his or her second year of training and serves as the direct supervisor of the interns and medical stu- dents. The junior resident is expected to be the “manager” of the team and ensure that all the work is done properly.

• The senior resident is in his or her third and ﬁnal year of training and is often thought to be the “oil of the machine.” Although not entirely required for the functioning of the team, the senior resident can play more of an educator role for the students and interns. At the time of the conﬂict, the senior resident was in the emergency depart- ment evaluating an ill child and thus was not present for most of the events.

• The teaching attending physician is responsible for the general operations of the inpatient unit as well as being ultimately responsible for the actions of the residents.

• The primary care attending physician is the person who cares for the patient outside the hospital. In this case, the primary care attending physician was one who was thought to believe that residents were somewhat of a nuisance and were useful only for doing the “dirty work” of inpatient hospital care—paperwork, procedures, etc.

She offered little support in managing the conﬂict.

• Third-year medical students on the unit generally work alongside the intern in the day-to-day care of patients. They are responsible for looking after patients assigned to them but are not held accountable for the daily paperwork. This team had two third-year medical students.

Further Developments

The patient’s family dynamic and background also played a large role in this conﬂict.

In the local refugee Hmong culture in central California, the family dynamic is matri- archical. Often the eldest female member of the home becomes the head of the house- hold even if she is not truly biologically related to the rest of the family. Another complicating factor in this culture is that the community as a whole is extremely impov- erished. This potentially could lead to resentment and mistrust of those thought to be more privileged.

I learned of the conflict at about the time that the security guards were about to be summoned. I was giving a lecture to the medical students when one of the residents interrupted my presentation to let me know that the conflict was happening and that they needed my help. I approached the teaching attending physician and asked if I could attempt to resolve the conflict. I then sat down with the resident team to find out 230 Section VI. Organizational and Interpersonal Conflict

LTF24 10/11/2004 9:14 AM Page 230

(3)

what had happened and what the issues were from their perspective. Next, I went into the child’s room to speak with the family. I introduced myself as the supervising resi- dent and asked them to tell me their side of the issue. Through an interpreter, they relayed their feelings of mistrust and anger toward the residents. I asked the child’s aunt about her accusations of racism and if she had attempted to strike one of the interns. The family felt their child was being singled out for frequent blood draws that were not being performed on other children. She also reported that she had not intended to strike the intern but was merely expressing forceful emotions.

I explained that the reason that other children on the unit were not subjected to fre- quent tests was that they were not as ill as her nephew and that everything done up to this point would be considered standard care for any child with his diagnosis and clin- ical condition. I also pointed out to her that if someone did not know that it was accepted behavior in their culture, the person experiencing her “forceful” emotional outbursts would in fact be quite intimidated and fearful. I then asked them what it would take to reach a compromise in this matter. We eventually agreed that the con- ﬂict seemed to arise from a series of miscommunications and misunderstandings. I offered to supervise the remainder of the child’s stay personally.

The aunt and mother were satisfied with this resolution—feeling that they had developed sufficient trust in me and that an acceptable solution had been found. I then notified the primary care physician of the events that had transpired and the agree- ment that had been made. Finally, I settled down to write a long note to document the conflict.

Analysis

Looking at how this situation unfolded, I can see several factors that contributed to the conﬂict. First, there seemed to be a lack of communication between the family and the treating team. This is evident in the family’s view that the child was receiving treat- ment different from that given other patients admitted at that time. Another illustra- tion of this is the family’s lack of understanding of the expected clinical course. Further communication breakdowns occur on both the physician-to-physician level and the physician-to-patient level, as seen in the family’s overall lack of understanding of the treatment plan or clinical course. Last, the family’s concern about racism serves to illustrate the general mistrust the local culture has toward the medical community.

There are several examples in the literature of how good conﬂict management skills could have avoided such a situation. Merideth and Mantel

¹

provide an excellent syn- opsis of the major issues involved in conﬂict management. They emphasize that nego- tiation skills are of critical importance for any project manager. Weiss and Wysocki

²

also provide a good review of some of the accepted methods of conflict resolution in a project design. To extrapolate the concepts of project design and management to the clinical setting, anticipation and advanced preparation may have avoided the entire conflict. For example, if the resident team had anticipated the anxieties and appre- hensions of the family, they might have been able to recognize that there was a signif- icant degree of mistrust directed toward them. Empowered with knowledge, the team could have sat down with the family and outlined a detailed treatment plan including contingencies for unexpected results prior to the onset of treatment. With regard to the interaction between the resident team and the primary attending physician, much of the conflict could have been avoided if they had discussed the treatment plan and the compromises that had been made.

24. The Chief Resident’s Dilemma 231

LTF24 10/11/2004 9:14 AM Page 231

(4)

Overall, this conﬂict illustrates that negotiation should be focused on obtaining the best outcome rather than trying to win. In this case, the best outcome would have been proper care for the patient and enhanced family satisfaction. Thus, with proper appli- cation of project management techniques, this conﬂict may never have occurred.

References

1. Merideth JR, Mantel SJ. Conﬂict and negotiation. In Project Management: a Managerial Approach, 4th ed. New York: John Wiley, 2000:226–58.

2. Weiss JW, Wysocki RK. Managing people and project relations. In: 5-Phase Project Manage- ment. Cambridge, MA: Perseus Books, 1992.

232 Section VI. Organizational and Interpersonal Conﬂict

LTF24 10/11/2004 9:14 AM Page 232