When Loyalties Clash

Dr. Jones had excellent bedside manner. She listened empathetically to patients and exuded a comforting energy. The staff liked her. Her patients were devoted to her. The residents enjoyed her easygoing style.

The first time my chief resident assigned me to be Dr. Jones’ surgical assistant, I was relieved. As an intern fresh out of medical school, you always breathe easier operating with a laid-back attending. My chief resident reminded me that I should call her for help at any time. She didn’t expect any trouble though. It was a routine minor procedure.

The case started out well. Dr. Jones told the anesthesiologist the whole surgery would take 15 minutes. We would be filling the uterine cavity with sterile fluid, looking inside with a small camera, and then sampling the lining for pathological evaluation. I maneuvered the camera into the uterus easily, but couldn’t see certain areas, so I handed the instrument to Dr. Jones. She also struggled with visualization. At this point, an alarm sounded on the machine that monitored the amount of fluid we were injecting into the uterus. I commented to Dr. Jones that the number looked higher than expected and asked if she would like me to call for a more experienced resident. She said we would be done shortly and was annoyed that I seemed to suggest she couldn’t handle a simple case. The alarm continued to beep. The patient’s oxygen level was decreasing. I quietly asked the nurse to page my chief resident. I didn’t know what was wrong, but I’d rather be the na├»ve intern who overreacted than the doctor who missed a serious complication.

My chief resident came immediately and argued with Dr. Jones to end the surgery. The patient’s oxygen level was still low. Dr. Jones ignored her pleas. My chief told me to find another senior attending NOW. Panicked, I went into the neighboring room where a cancer surgery was starting. I sheepishly asked the oncology attending if he could please come help. This attending looked at me with extreme irritation, but when he heard what was happening, he relented with a deep sigh.

Back in the operating room, the oncology attending took one look at the patient’s vital signs, the fluid on the floor, and the alarm, and firmly told Dr. Jones to stop the case. Dr. Jones glared at me. I felt like a traitor.

In the recovery room, the patient was found to have excess fluid in her lungs. Dr. Jones looked on nervously. I waited for her outrage, but she merely instructed me to call her with an update in two hours. After Dr. Jones left, the nurse patted me on the shoulder and told me I did the right thing. She stated vaguely that Dr. Jones had a “pattern” of surgical mishaps.

Over time, I learned that Dr. Jones’s surgical inadequacy was an open secret. Her family was well connected in the medical community. The staff didn’t want to bring complaints against an established surgeon, perhaps fearing for their jobs. The residents were in no position to criticize a higher-level physician. So, we all compensated for her incompetence, finding quiet ways to protect her patients from real harm.

Where does a doctor’s loyalties lie? Recently, this question of allegiance has come up in a very public way in executive boardrooms and on legendary sports teams. It’s a serious conundrum anywhere powerful figures are entrusted as stewards and held to high ethical standards. What do you owe to your colleagues, versus what do you owe to your constituency?

In medicine, this conflict of loyalty has direct consequences. Doctors have a fundamental duty to their patients; that is the job. The stakes are high. However, we, as a society, don’t have a good system for accurately and objectively assessing surgical skills. If colleagues can’t or won’t grade each other, patients are even less likely to know how to make good choices.

There is an unspoken code in medicine that you don’t rat out another doctor. Instead, you watch each other’s backs, especially in the current litigious environment. People devote over 8 years of their lives to medical training, and then it’s a lifelong commitment to remain board-certified. You never want to destroy someone’s career, especially people whom you spend 80+ hours a week with, good people who are your friends. Moreover, you could easily be in that person’s shoes. We all make mistakes. You would wish that others would treat you with a measure of grace.

A year after that initial experience with Dr. Jones, I was on call with her when a patient required emergency surgery in the middle of the night. I grappled with the issues of Dr. Jones’ questionable abilities, professional camaraderie, and moral responsibility to the patient. Would this be one of those times when everything turns out fine despite the imperfect doctors involved? Or would it be a catastrophe I should have had the insight to prevent?

I called my chief resident, who assured me that she could be at the hospital in 10 minutes if I needed her. To date, that is what I have learned about managing conflicting loyalties in medicine. Good doctors have the humility and confidence to know when to ask for help. There is no shame in acknowledging human limitations.

Emboldened by the reminder that my team had my back, I picked up the scalpel.