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Know Your Place?

Luciali72x721Lucia Li -- “In a hierarchy, people tend to rise to their level of incompetence.”

In the hierarchy that is medicine, you enter at the bottom as a lowly medical student and attempt to make your way to the lofty heights as a consultant. Self-evident from the start, this unwritten hierarchy is followed by all. Which really makes life difficult if you feel the need to break it. This hierarchy is based on knowledge, with the presumption that your superiors will know more than you. And, by extension, are more right than you. But, just occasionally, that’s not the case, and then all the fun begins…

In one of our lectures, we were told an anecdote about a surgeon who was conducting a left nephrectomy. However, on the same day, a right nephrectomy had also been scheduled… you can guess what happens next. The anecdote goes that although the medical student observing that day thought that this was the wrong patient, he didn’t say anything. Maybe he wasn’t sure what was really going on. Maybe he wasn’t sure that this patient wasn’t the right nephrectomy patient –- it is, after all, often easier to doubt yourself than someone senior. Maybe he was just hoping someone else would say something?

Happily, most consultants I’ve come across treat their team as just that; management plans are formulated together with the flow of ideas and information going both ways. This is as much a teaching process as patient care, so there are advantages for all parties.

But as medical students, it can be hard to feel like you’re ever in a position where you can correct a senior. Maybe it’s because as students, we don’t feel qualified to do anything yet, never mind suggest to a senior that we think they might be wrong. Maybe it’s because in our current situation, where we don’t really have a job or our own patients, we don’t feel enough part of the team to say anything.

In this lecture, we discussed if there were possibly ways to deal with this issue, and the idea came up that being a medical student was positively advantageous. Asking the surgeon to talk through what he’s doing or, as one of my colleagues put it, “to express keen interest in the unusual approach” seems a fairly tactful way of doing things. After all, as a medical student, it’s practically our privilege to be a bit ignorant!

December 7, 2008 in Lucia Li | Permalink


speaking up is a good thing, even though it can be nerve wracking. I had such an instance today where we had a case presentation and then were able to interview the actual patient. In a room full of attendings and residents, I spoke up first to give my view of the case, in my limited knowledge, and yes, as a lowly medical student. After I gave my spiel, which no one seemed to elaborate on (in fact the subject was changed after I finished talking), I felt like I should have just shut up and presumed the student role which involves nervous waiting for pimp questions. After the presentation was over, the head attending came to speak with me personally and said I had good insight into the case, and that his thinking in the differential was greatly influenced by my thought process. I was like, wow, and here I thought what I had to say went in one ear and out the other of everybody in the room. Goes to show that even us at the bottom of the totem pole can make waves if we have the courage to try!

Posted by: MG | Dec 9, 2008 7:20:43 PM

Thanks for the posting. I loved it.

Posted by: Carlton | Dec 10, 2008 9:16:12 AM

Excellent post! And congratulations MG :)

Posted by: | Dec 10, 2008 9:51:59 AM

I guess you have to remember that superiors are just that, they are not any closer to god. Everyone makes mistakes, and mistakes have to be corrected if possible.
Even a beginning med student knows the difference between right and left, so speak up if youre doubtfull.

Posted by: Benny van der Tak | Dec 11, 2008 3:49:52 AM

"... Asking the surgeon to talk through what he’s doing or, as one of my colleagues put it, “to express keen interest in the unusual approach” seems a fairly tactful way of doing things..."

- I'm only 2nd year medical student (Australia) and it partly saddens me that if a senior physician/surgeon mixed up a patient or performs some sort of mistake, that the medical student needs to use a non-direct and 'roundabout' method to tell the senior that he/she may very well have messed up, in order for them not to lose 'face' or sense of superiority (or humiliation of being reminded by an apparently lowly medical student). Gee that was a long sentence. I guess it really depends on the attending/consultant. He or she may take the advice well, or not.

"... After all, as a medical student, it’s practically our privilege to be a bit ignorant!"

- Yes, there's some truth in that but if it's something like mixing up a patient for a surgical procedure, that's a pretty big mistake and if a student spots it out then he/she should speak up.

In my opinion speak up if what someone is about to do may be harmful to a patient - whether that be a resident, attending or whatever. Patient first, always.

Posted by: Ray | Dec 11, 2008 6:18:45 AM

As a medical students, speaking up in some situations are advantageous but most times, they are to the disadvantage of the student. However like every student knows one day if they persevere like their senior colleagues have done, they will arrive at their expected destination and find their rightful place.

Posted by: Ayodeji Borokinni | Dec 15, 2008 3:55:12 PM


Posted by: GATI KRUSHNA BEHERA | Dec 21, 2008 4:31:54 AM

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