Flatten the Hierarchy, but Blame the Intern?

Wow what a great 3 days the Telluride Experience has been thus far. My eyes have been opened to the small, innocent miscommunications that can ultimately lead to patient and caregiver harm. Whether it is the missed after hours critical lab value or the anchoring bias causing us to miss diagnose Angina for GERD, no one is invincible to the patient safety events we have been discussing this week.

However, with all of the amazing lessons learned and the strategies to improve communication, I can’t help but feel defensive after each case and video we discuss. Maybe it’s because 90% of the patient safety events are surgical or procedural and I am one of the only surgeons in the room? Maybe it’s because not too long ago I was the intern having to work up abdominal pain in a post-op patient? I feel emotionally exhausted every day because of the pain I feel for the patients and families who have been harmed, but also for the surgical team who ends up being blamed. I become especially frustrated and defensive when I keep hearing, “but they sent the intern” or  “I didn’t even know she was our doctor, I thought she was a nurse”.

How can we advocate for “flattening the hierarchy” when we are also communicating that “the Intern” isn’t a reliable or meaningful member of the care team?

How can we expect an Intern to confront their attending when a near miss is occuring, when we won’t even allow Interns to manage post-operative patients on the floor?

How can we educate and train future surgeons when our patients don’t want us involved in their care?

I hesitate to even write these thoughts and feelings in a public forum, but I would feel like I am doing my fellow surgery trainees an injustice if I did not voice my concerns. I think what I will take away from these conflicting emotions I have been feeling, is that in order to truly flatten the hierarchy and prevent patient harm, patients and caregivers (from interns, to nurses, to attendings, to hospital administrators) must have mutual respect for one another. It’s like the MedStar marketing video we viewed today, our patients want to be SEEN but shouldn’t they also SEE their providers? The attendings may be the physician in the chart, but the intern is the defender of the floor and the provider with all the details of the day to day changes of the patient. If we cannot trust our interns to effectively communicate to the remainder of the care team, can we trust them as an attending when their name is in the chart?

Let’s flatten the hierarchy, but lift up the interns. Then we will truly be on an even playing field.