Speak no evil


Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

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19 Responses

  1. Avatar Vikram Bath says:

    “Culture of respect” sounds nice and fuzzy enough.

    But if we are to pick between falling on the side of being somewhat overly critical of others in our profession and somewhat overly accepting, I’d rather see the former. Criticality within a profession isn’t the same thing as learning, but a profession in which everyone feels pressured to never criticize anyone else is unlikely to make as much forward progress as it could.Report

    • I concur.

      The article presents the results of the study as clearly indicative of a problem, but doesn’t make clear (and I’m not shelling out the cash to access the full study results) what grounds the subjects for criticizing the care the fake patients received. Frankly, I don’t consider it problematic if they were critical of management they considered substandard. It should have been expressed respectfully, but patients are entitled to know if one doctor thinks another’s treatment has been incorrect or outmoded or inadequate.Report

  2. Avatar Kim says:

    I am of many minds on this:
    1) It’s probably good practice to assume that it was a mistake, at least in cases where there is reasonable doubt.
    2) If the doctor is endangering his patients, you have an ethical reason to speak up (and contact the relevant review board, if appropriate) — also you have an obligation to tell the patient.
    3) In an arena of shared responsibility, educating ones fellow doctors is just part of the ongoing conversation. It ought to be encouraged.Report

    • In some of those other examples I refrained from detailing, I had strong suspicions that my patients had received some kind of flawed care, and expressed those suspicions. However, I did not have a basis to report anyone for board review.

      And I hope it’s clear that I would welcome feedback from colleagues about how I can deliver care better, and frequently solicit if from my partners in practice. I just expect that any feedback be respectful, and when appropriate given directly to me rather than in the form of maligning me to a mutual patient.Report

  3. Avatar Troublesome Frog says:

    If the work was objectively bad, I don’t think I have a problem with professionals letting their clients know, but I think that most industries often suffer from, “blame the last guy so you look better” syndrome.

    It’s particularly bad in the software industry where there are a lot of ways of doing things. There are a lot of people who are writing really terrible software. There are also a lot of people who think that any code they didn’t write is terrible software, and they’re not shy about saying it. That doesn’t necessarily help the client understand what to look for.Report

    • Insofar as physicians (or other professionals) denigrate each other for the sake of making themselves look better, then it’s a habit that should be broken.

      But I think the article elides (or at least fails to make clear) how much of this supposedly-harmful badmouthing is premised on good-faith concerns about care delivered.Report

  4. Avatar BlaiseP says:

    Wouldn’t the medical profession benefit from some sort of self-regulating body, much as lawyers have the Bar Association? It would seem to be a natural fit. Many medical practices are incorporated as partnerships, surely these partnerships could band together in some sort of ad-hoc, if not entirely formal, self-regulating mechanism.

    Everyone wants a second opinion. In my business, I’m extremely reticent about reviewing my own code. I want someone else to read it all, at least be aware of the decisions I’ve made and what I’ve done on that basis. Scares the willies out of me, every time I have to deploy production code. I’ve gotten to the point where I have the client deploy it.

    Especially liked this bit: But doctors are all too human, and we make mistakes. And if a mistake has been made by another medical provider on one of my patients, I see no reason why I shouldn’t say so.. Not only should you say so, the other provider should be professional enough to seek out your opinions — since everyone makes mistakes and nobody wants to make them.Report

    • Medicine does not suffer from a lack of regulation. Between the American Board of Pediatrics, the state board of licensure and the medical staff offices of the hospitals where I have privileges, my work has no shortage of people making sure I am educated and certified and scrutinized… a lot.

      As far as the actual provision of patient care goes, I am always happy to hear from colleagues about ways of improving the care I deliver. I would hope that any halfway decent medical provider would display the attitude you describe. But I don’t know that a national entity empowered to audit my charts would be the way I’d want it to happen.Report

      • Avatar BlaiseP says:

        I’m not thinking about some external entity. I’m thinking more of a professional association, more akin to my ad-hoc circle of specialists. Can’t be good at everything, hard as you might try. Even if it’s just on an experiential basis, say for example — okay, here’s where I’m out of my league, just saying — tropical diseases. I will suppose you don’t have much experience with pediatric malaria. What are the current best practices for pediatric malaria? Common enough disease, you just don’t often run across it in your practice. But some child from Ghana turns up in your office — what now?

        Domperidone is often prescribed as an antiemetic in the treatment of pediatric malaria. Lots of controversy around domperidone. But it’s used all the time, treating pediatric malaria in other countries. Lots of antimalarials have lost their effectiveness, what do you prescribe? Who would you turn to for a course of action on this? Someone with experience, obviously. That sort of discussion — that’s what I’m looking for in this hypothetical internally-organised organisation. So you get someone who’s handled lots of pediatric malaria — he says “Domperidone is a great antiemetic” — you say “FDA doesn’t think so.”

        That sort of discussion….Report

      • Well, in your hypothetical I would contact the infectious disease consultant on call and arrange for immediate evaluation. I’m lucky to be on staff at a couple of premier institutions, where if they don’t have a pediatric malaria specialist handy can get the current best recommendations from whoever the world’s expert may happen to be at any given time.

        And we disregard the FDA all the time, even if we’re not the world’s expert in anything.Report

      • Avatar BlaiseP says:

        That’s good to hear, exactly the sort of fallback position I’d want to see.

        But for some GP, far from the resources of an elite institution such as yours — who would he turn to for advice? I’m not a lawyer, either, but I could call the local Bar Association and ask “I need an attorney specialising to torts. Got any recommendations?” I wouldn’t just go down to the nearest J.D. — but if I did, only to find this guy did wills and divorces — I would he’d he’d steer me in the right direction.Report

      • At my old job, where I had much less access to a battalion of world-class experts pretty much round the clock, I’d have to do more managing of complex stuff myself. Much of it was stuff that I felt comfortable managing, though the mental health aspect made me uncomfortable and I had to deliver more high-acuity care than I liked. (See also: reasons Russell found a new job. ) But for something obscure like malaria, I would call either the nearest major medical center or even get on the horn with someone from Children’s and try to figure out what best to do.Report

  5. Avatar Jaybird says:

    I imagine that a lack of solidarity would result in a non-trivial number of patients being unable to see the difference between Doctor Emmdee and Doctor Deoh having a very ugly disagreement and Doctor Emmdee and “I’m More Of A Therapist Really” Bellringer having a very ugly disagreement.Report

  6. Avatar Slugger says:

    First, always be a little careful about believing the patient about what the other doctor said. I have seen many misquotations, and innocent remarks couched in professional jargon often sound worse to the patient than they actually are. It is rare for patients to ask for clarification even when they clearly don’t understand what was said.
    Secondly, self-important entitled sphincters are not rare in the medical profession. I have been one myself on many occasions. Often, they will treat a colleague better than a patient. Keep a mental file of these people.
    Lastly, are you totally innocent here? Did you speak to the consultant before the patient showed up? This prevents some of these conflicts.
    Ars longa, vita brevis est.Report

    • I am omitting some of the nuances in the story. It is possible that what was communicated to me by the parent wasn’t entirely accurate, either. Which is why I was assiduously polite in my e-mail, and did not start with “Dear Dr. Asshat.”

      For referrals where there is a complicated question, I often will communicate with the specialist before the appointment to discuss the reason for referral. This was a relatively straightforward case that did not seem to warrant it. It would be an onerous process to track down which particular specialist my patients were seeing and communicating with them directly each time, as ideal as that may seem. It probably wouldn’t have obviated the need for the appointment in this case, but (as I allude) it would have spared the patient a (non-invasive, minimal-risk) test that could have been avoided.Report

  7. Avatar Kazzy says:

    This is something that seems like a good time to “critique the act, not the actor.”

    “The cast failed to set the bone correctly,” is a presumably objective analysis of what happened.
    “Whoever did this is an idiot,” is a subjective critique, perhaps based on an objective analysis but which requires at least some assumption.Report

    • Avatar Mike Schilling says:

      I’m realizing now how often, while trying to figure out how some piece of third-party software works, I say “God, those people are idiots.” If you took that sentence away I’d be a mute.Report

  8. Avatar Burt Likko says:

    I am reluctant to criticize another lawyer’s work or diagnosis, although many clients have invited me to do so. The reason for that is that it is very, very easy for a client or even a set of documents to omit something that may well offer a reasonable explanation for why another lawyer did something that I don’t think was the right call. It’s also easy to look back on something and say, retrospectively, that it was a bad call. So while I’d happily point to another lawyer who really screwed the pooch and say so (were that in my client’s best interests) I’m naturally reluctant to say that the other lawyer really did screw the pooch since it’s damn near certain that she knew something I do not.

    My presumption is that when other kinds of professionals have differences of professional opinion, a similar ethic ought to apply. It seems cautious and prudent.

    But I get that medicine is supposed to be a science and that medical reports are supposed to be different than subjective oral reports of past events that come from law clients. There’s supposed to be something like complete information in there. In theory, one ought to be able to take a file from another office and see records of observations and reports of symptoms, and re-create the process and come up with a similar result. That’s not to say there isn’t an art along with the science — probabilistic diagnoses, for instance, can be interpreted in various ways that are still reasonable even though they vary from one another, and once you have an array of treatment plans available as well. But all the same, it seems that one ought to come up with at least similar ideas in similar situations.

    So when I occasionally encounter these sorts of condescending, dismissive, and insulting responses to varying opinions, as you report in situations where varying diagnoses and plans of treatment arise, I’d suggest that this is more indicative of condescension, dismissiveness, and propensity to insult than it does to any particular facet of the profession. There are those people, after all, who really like being The Authority Figure and when their judgments are questions they react very poorly.

    TL/DR: Some people are assholes. Not much you can do about it.Report

  9. Avatar Pierre Corneille says:


    This is only a tangent, but how much do you think the fact that you emailed the other Dr. instead of calling him or talking to him personally, may have made the situation a bit more uncomfortable than it might have been?

    I say this because I have often made the mistake of trying to address delicate situations through email rather than in person.

    Again, I realize this is a tangent to your main argument.Report