At some point, I’m going to witness patient care that I will not comfortable with. I’m probably going to be asked to do some things that I will not be comfortable with. And it’s going to be up to me to draw the line.
Right now in family medicine, the stakes are relatively low. Maybe a patient gets an antibiotic to treat a (90% probability) non-existent or viral URI. Maybe a patient gets an unnecessary PFT or CXR. Maybe someone gets referred to a cardiologist or pulmonologist to deal with abnormal results on tests that no one should have ordered in the first place. In my current setting, both the harm of these events and my ability to effect change are quite low. Even if I pulled out my soap-box and told a patient not to get a CXR that their trusted (well, sort of …) primary care physician had ordered, would they listen? And what harm could one little CXR or 10 day course of cefdinir or levofloxacin do? Certainly I would never recommend those things in the way that I have seen, I wouldn’t write them in my plan, or advocate them if asked directly by a patient. But for the most part I am comfortable following the direction of more senior physicians even if their treatment plans do not correspond with national or professional guidelines, since physicians have a right and a duty to consider each patient individually. That doesn’t mean I have to agree with their plan – just that I haven’t seen anything that would cause significant* harm or any significant* errors.
But, listening to my friends who are on different rotations, I realize that the stakes will soon increase exponentially (I’m starting OB/GYN in September, then Surgery in November). I don’t want to be more specific since repeating these concerns would tread the line between slander, malpractice and hearsay, and I haven’t observed any of these things directly. But, I know that I will soon be thrown in the midst of issues related to lack of informed consent, lack of proper documentation of errors, issues that can cause serious patient discomfort or harm. At some point in future I will need to make decisions about how to handle these issues. I hope I’ll have the courage to make decisions that I feel are right, even if they are difficult or unpopular. I get the sense that my fellow students are faced with serious, significant, and even dangerous conditions, and are called upon to make personal decisions about how to handle themselves (if not their patients).
*= These are weasel words, I know. And that is what gives me pause. There are no clear answers: maybe I should make a vocal stand every time an antibiotic is given against guidelines or a PFT is ordered for an asymptomatic 25 year old … but these things don’t keep me up at night … yet.