A young doctor’s fear of raising questions causes a mistake


The “hidden curriculum” tells new doctors not to rock the boat, to do what they’re told even when in doubt (Brett Ryder)
March 24

The patient was 35 weeks into an uneventful pregnancy when we met in the prenatal clinic of the county hospital where I was working. I introduced myself as a third-year medical student working with her physician as part of my obstetrics rotation and learned from her that she was 27 and pregnant with her second child.

A month later, I was rotating through the hospital’s labor and delivery unit, when the same young woman came in with strong, sustained cramps. She was admitted, and her labor continued over the next 10 hours. As delivery neared, the supervising resident physician and I got ready to count her final contractions with her.

At that moment, the senior obstetrician assigned to the delivery stalked in, visibly upset. There was risk for shoulder injury given the baby’s size, she snapped at us, and she should have been notified. She shook her head briskly, muttered under her breath and stepped in front of the resident, who then sternly ordered me aside.

As I watched from the corner, the obstetrician and resident delivered a healthy, vigorous baby girl. Without saying a word, the doctor took her gloves off and left.

The resident, meanwhile, was stepping in to sew up a minor laceration, a common complication during labor, when he called me to the foot of the bed and said I should deliver the placenta (that is, remove the placenta from the uterus as a part of standard post-delivery care). I’d never delivered one before, I said. I’d only observed.

“So?” the resident responded tersely without looking up. I remained silent, and she finally turned toward me with a frustrated look. “You’ll do fine. You know how we learn in medicine: See one, do one, teach one.”

Sensing my continued hesitation, the resident released an impatient, staccato sigh. “Look, I don’t have time for this,” she said. “Apply the clamp and give traction but not too much. Just get it done before [the obstetrician] gets more pissed!”

Uneasiness

I wanted further guidance, but I could sense that the resident was upset and embarrassed, having been scolded by the obstetrician in front of everyone. I feared her disapproval more than my uncertainty, so I pushed the uneasiness out of my chest with a long breath. I locked a clamp onto the umbilical cord and pulled.

It came out smoothly at first, coiling easily around my clamp. The resident glanced over without speaking, a quiet affirmation I was doing it correctly. I continued, gaining confidence as I went, until suddenly, without warning, the cord went slack. I glanced down in disbelief at its torn edge, dangling from my hand. Jets of blood sprayed across my gown.

“Oh, my God,” the resident said from behind me.

She looked into my eyes. “You tore the cord.” A torn cord can make it difficult to deliver the placenta, increasing the risk of serious bleeding for the mother.

The next few minutes were a blur of voices and passing figures. The resident reached into the patient’s uterus to manually free the placenta. Nurses moved across the room with supplies. A pulse of heat swelled behind my ears, and I felt my heart pounding. As I scanned the room, my gaze caught the patient’s. She was disarmingly still amid the chaos. Her eyes stared intently into mine as if searching for something reassuring in them, compelling me to look away.

Soon the doctor returned, barking orders at the staff. She dismissed me from the room and pulled the curtains shut, a clear message that I was officially off the case. It was not until the next day that I heard that the problem had been resolved and the patient had recovered well.

I worked in the labor and delivery unit for another two weeks before finishing my rotation. Although I interacted with the resident and obstetrician again several times, we never discussed the incident. And I never saw the patient again.

The aftermath

In the months that followed, I thought repeatedly about the incident. I consulted with colleagues and read medical literature to try to process what had happened that day. I discussed the event with experienced clinicians. All of this not only helped me better understand the experience but also helped me identify missed opportunities for safety, learning and growth for both me and for the system around me.

I had been involved in a number of patient-safety efforts. I founded the first patient-safety interest group at my medical school and worked with senior educators to create and lead a semester-long safety course that all students were required to take. I mentored younger students with similar interests and served in national leadership roles for several patient-safety organizations.

None of that, however, had prepared me for an experience with the harm that can come not from insufficient safety knowledge or understanding but from poor communication. It was my first encounter with the danger that can occur when team members feel they cannot speak up.

The ‘hidden curriculum’

Medical school educators around the country are trying to improve patient safety through formalized curricula. But there is a different, far more influential “teacher” that has been shaping the behavior of young and seasoned physicians alike. This “hidden curriculum,” as it has been termed, refers to the messages transmitted implicitly through everyday vocabulary, practices and habits, all of which have powerful effects on individual attitudes and practices. This phenomenon is particularly relevant to medicine, which has long-standing and often rigid traditions about hierarchy that allow the actions — positive and negative — of senior physicians to strongly influence student behavior.

Of course, many physicians value their roles as teachers and role models, and generations of students have been inspired by masterful doctors. Unfortunately, some implicit lessons can contradict explicit teaching about safe practices — with potentially dangerous results.

For decades, medical students have described mistreatment by superiors — instances in which superiors treated patients in dehumanizing ways or directed harsh, derogatory language at students and at patients. Some have even reported seeing superiors falsify charts or feign medical proficiency when obtaining patients’ consent for treatments and procedures.

Pressured to accept a “team player” ethos and fearful of academic repercussions, many students do things they believe are wrong to fit in with the team. Students can become so rapidly assimilated into this kind of culture that they begin perceiving such behavior as acceptable. Later, they are at risk of propagating these practices to future generations of doctors.

Many institutions now advocate zero-tolerance policies for unacceptable behavior (profane language, throwing objects, bullying, etc.) and provide mechanisms for reporting disruptive physicians.

However, when we think about the more subtle team dynamics exemplified in the pregnant 27-year-old’s case, that kind of behavior is just the visible tip of a much larger iceberg. Far more prevalent are the subtle behaviors that threaten patient safety but go largely unnoticed and unaddressed. Sometimes it’s a sarcastic joke about students who ask too many questions. Or a physician muttering under her breath that she “doesn’t have time for this.” Or a supervising doctor responding to a student’s hesitation with impatient, even angry, sighs.

In fact, enabling doctors-in-training to speak up and making them feel safe while doing so may prove far more challenging than getting rid of disruptive doctors.

Raising awareness

Medical schools and teaching hospitals can raise awareness about the hidden curriculum and its impact on safety.

Educators can ask students for feedback through surveys and focus groups that are guaranteed to be confidential and non-punitive. They should also actively provide this important feedback to other educators and front-line physicians, who may be acculturated and no longer “see” the types of issues that are apparent to beginners.

Hopefully these steps can lead to necessary changes. Nothing will stifle progress more than asking students to speak up and then doing nothing in response.

Ultimately, students, clinicians, schools, and health-care organizations must take collective responsibility for creating a new culture — one that lets students, residents, faculty and even patients feel confident about speaking up.

This story was excerpted from the Narrative Matters section of the journal Health Affairs and can be read in full at www.healthaffairs.com. Liao is a resident physician at Brigham and Women’s Hospital in Boston, and the co-founder and chair of the Brigham and Women’s Hospital Housestaff Safety and Quality Council. Two of Liao’s mentors co-authored the policy portions of this story: Eric J. Thomas, a professor of medicine, an associate dean for health-care quality and the director of the University of Texas at Houston — Memorial Hermann Center for Healthcare Quality and Safety at the University of Texas Medical School at Houston; and Sigall K. Bell, an assistant professor of medicine at Beth Israel Deaconess Medical Center and Harvard Medical School and the director of patient safety and quality initiatives at the Institute for Professionalism and Ethical Practice at Boston Children’s Hospital.

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