H

e struggled to hear when people talked to him. He asked the same questions over and over. He fell asleep when really important conversations were going on around him.

But it wasn’t until he missed an emergency call that I knew I had to act.

I spoke to a higher-up about this elderly doctor out of concern for patient safety, and for several weeks the guilt tested my dual loyalties — one, to the people in my profession, and two, to my patients.

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On one hand, it didn’t feel right throwing another doctor, especially one of color, under the bus. After all, we are few and far between and need to support each other. But on the other hand, I was seriously concerned that his ability to care for patients properly was compromised.

The doctor was a locum tenens, a traveling physician who covers for other colleagues when they go on vacation or maternity leave. Parachuting into a hospital setting is challenging for the most acute-sensed doctor, but for this man, who struggled with electronic medical records, whose hearing aids barely worked, who would write discharge notes for patients I’d already sent home, I’m sure it was worse.

I was a resident. I was supposed to be learning from him. Instead, I felt like I was cleaning up after him, which I had no business trying to do.

The night after I spoke about my concerns, I couldn’t sleep.

“I just feel really bad about what I did,” I explained to my husband. I could feel the tears pooling in my eyes.

I, the resident, was the only doctor who responded to that emergency. The patient was a complicated case, and I was frustrated that the more experienced doctor wasn’t there. My frustration fueled my complaint, but after the adrenaline died down, I wondered, had I done the right thing?

“That’s your snitch guilt,” he replied.

I was looking for reassurance, which I got from some fellow residents, but my husband was right. I didn’t want to do it, but I really felt like patients would suffer.

While the older doctor was working with me, two patients pulled me aside and asked me why was he so rude, why he didn’t listen, and why he was so unprofessional. I didn’t want to undermine this attending physician or the trust that should have developed between him and our patients. I defended him, offering flimsy excuses — maybe his hearing aids weren’t properly adjusted — to convince our patients he was a good doctor, even as I knew these were terrible justifications.

Did his decades of experience matter if he couldn’t communicate well? What if he actually wasn’t a good doctor? I hated being in this position.

I wasn’t the only one — a social worker and another medical student pitched in to try and keep the ship afloat. But we were ancillary and less experienced. This was about authority, but it was also about trust. I didn’t trust him.

This was a complicated situation, but perhaps not uncommon.

In his book, “Complications: A Surgeon’s Notes on an Imperfect Science,” Dr. Atul Gawande wrote that whether due to age, or substance abuse, or even plain incompetence, “3 to 5 percent of practicing physicians are actually unfit to see patients.” And to further complicate matters, he wrote, the people “in the best position to see how dangerous” these doctors have become, are often in “the worst position to do anything about it.”

So the typically danger looms, until somebody gets hurt.

To be fair, there are plenty of elderly doctors who are really on top of their game — I work with many every day. But could my concerns about this one doctor be part of something that might become more common?

According to the the Federation of State Medical Boards, the number of actively licensed doctors age 70 and older grew from 75,627 in 2010 to 94,969 last year — it’s unclear how many still practice day to day.

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What’s challenging is that doctors can’t always tell when their skills are declining. One article described an elderly surgeon who could not find his own office after a day of surgery. Another article in Annals of Surgery told of a surgeon who fell asleep during surgery and another who operated on the wrong side of a patient’s brain.

Some hospitals are considering policies requiring cognitive testing for doctors over a certain age. While this could make a difference, I wonder if these policies are fair? Or perhaps discriminatory?

My guilt was also driven by the idea that I might be negatively impacting someone’s career, that my words carried weight.

In grade school, we complained about an English teacher who seemed to be fixated on one lesson for weeks and weeks. The school didn’t invite her back to teach the following year, and I saw her dressed as an elf at a Santa display at the mall. My words derailed her career.

I wonder what will happen to this elderly doctor — I doubt he’ll be invited back to my hospital, but if he does the same at another hospital, will a patient there get hurt? Either way, my guilt haunts me.

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  • You absolutely did the right thing. You would have a much harder time forgiving yourself if something bad happened as a result of that physician – and he would probably have a hard time forgiving himself, too. You acted out of true concern, not a personal vendetta. Also, you didn’t single-handedly revoke his license; there’s a whole process that will come after this to make sure whatever happens is fair (and safe).

    For the note about not wanting to hurt the career of a fellow doctor of color, it also looks bad for PoC if there is one practicing who is no longer competent, you know?

    I had to put in a request for someone’s driver’s license to be revoked recently (someone who’s young but had a new condition causing cognitive problems). I felt terrible about it – it’s going to make her recovery even harder – but… she could have hurt other people and herself if she kept driving. Our primary duty is to the public.

  • Doing the right thing isn’t always easy and sometimes it can come at a personal cost, but you did the right thing.

    As a rural resident, it does concern me that the ongoing shortages of health care professionals are leading clinics and hospitals to accept a lower standard of care – and for the public to adopt the mindset that this is OK.

    True story: Last year the local newspaper reported that an ER physician was disciplined by the state board for bombing out twice from an addiction treatment program and stealing narcotics from the hospital. They were bashed mercilessly for daring to tarnish the reputation of “a good man.” The spouse of a local state legislator even demanded that the paper publicly apologize.

    Standards are meaningless if the profession isn’t willing to uphold them. You were put in a difficult position but you made the right decision.

  • I have seen this across multiple professions. “Coworker has done Unacceptable Thing, but I don’t want to get them fired.”

    It is definitely time for us to do away with that mindset. Our complaints are not what gets someone fired; their unacceptable actions get them fired. All they had to do was Not Do The Unacceptable Thing. It does not matter whether the Unacceptable Thing was done with malice or intent or competence or a lack thereof. The Thing that was Unacceptable was done.

    I have seen this across all levels of employment. It affects retail workers, tradesmen, academia, cops, doctors, lawyers, tech, entertainment, politics, etc. You are by no means alone in feeling “snitch’s guilt”, but that guilt is misplaced. Remind yourself that there’s a reason some Things are “mistakes”, some are “inappropriate”, and some are, truly, “Unacceptable”.

  • “Throwing someone under a bus,” means that person is being made a scapegoat for something for which they weren’t responsible. That was not the case. As a physician, isn’t there a responsibility to “first, do no harm?” This doctor could have caused great harm. You did nothing for which feelings of guilt are appropriate.

  • My college roommate was a nurse working in a local college health service and she and her colleagues had to cover for a physician who was not competent. He fell asleep during physical exams! Students would come out to the nurses and say: “Is something wrong with that guy? I think he is asleep.” Thank goodness he wasn’t handling life and death situations, and thank goodness he had a bunch of capable nurses around him.

  • I have seen elderly MD’s still working past their abilities. Perhaps due to an extravagant family life style or divorce and new family, poor investments, they have no choice, other than to live on SS. Usuall they are found as locums in rural hospitals that are desperate enough to hire them cheaply. Certainly a sad situation. On Code Blue, I’ll run the code until they show up, if they show up. Give them a full report (Hx, EKG & labs) and suggest what’s needed next. After all, I also work Locums, but not for the same reasons. Were I full time, I’d talk quietly with others to verify my impressions, report it to the medical staff with documentation and let them handle it. I am a Nurse Anesthetist and it is their responsibility to police their own. I file My report c documentation in the event of “retaliation” which I’ve also seen.

  • Patient safety ALWAYS trumps any guilt that you may feel. I find it fascinating that despite all your education and especially as a psychiatrist that you believe your childhood complaint carried so much weight that it derailed someone’s career. Did it ever occur to you that perhaps this teacher enjoyed being an elf during a joyous time of year, did it occur to you that she went to teach elsewhere, why would you assume she wasn’t “invited back”? The childhood assumptions and guilt you carry forward into your adult professional career are disturbing and profound.

  • I think that you did a really difficult thing but ultimately the right thing. I work with a doctor like that. He is an excellent physician but he is was too slow to be the only ER physician at the hospital. I think that the hospital is trying to phase him out and he is fighting it on grounds of ageism….it’s possible to be a great doctor when you are older but when you have difficulty performing procedures, start to snooze towards the end of your shift, and go so slowly that patients are waiting 4 hours to be seen then it’s not discrimination, it’s holding you accountable for your responsibility as a provider. I honestly think he could still be an asset to patients but it would require him to have some help from other providers and I know that it wouldn’t be cost effective when you can hire a physician who is self sufficient.

  • An alternative is to contact patient relations/advocate on behalf of the complaining patients/families. They are employed by the hospital, aren’t really patient advocates, but are the pretty and benign face of legal risk management, and they can and will go up the chain.

    However, I don’ understand where guilt plays a part in a frankly unsafe patient care situation. If you’re unclear where your professional alliances lie: unsafe doc over patients, then that’s the fundamental problem.

  • Thank you from the bottom of all patient hearts. Recently there was a story that came out regarding doctors’ and patients’ losing their trust of them. The refusal to “police” their own and then telling us we are too stupid to understand why no one else can “police” them is why. I’ve seen it way too often. I’ve seen hospitals and other groups way too often gag order, blacklist, you name it, to stop the gravy train of money coming in from doctors’ mistakes. Thank you for recognizing this and for caring more about patients than money.

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