This past week, I had the fortune of hearing the tale of Bob and his bum knee.

It all started when Bob picked me up at the end of a busy clinic day in his neon orange Subaru. Given that this particular shared car service promotes friendly conversation, Bob started up the gab by asking me what position I held in the medical center. After describing my work as a resident physician in internal medicine, Bob nodded in acknowledgment and began to tell his story.

The Set-up

Bob commenced this unsolicited anecdote with a description of his days back in Oconomowoc, Wisc., just before the recession hit nationwide. After only a short time looking for a job, Bob received what he described as a decent offer to work in marketing. Given the fact that his mother was ill and he had ultimate plans to move out west, he decided to pass up on the offer and wait a few more months before reentering the workforce.

The rest of Bob's story unraveled like a made-for-TV movie: His mother's health declined sooner than anticipated and, sans employment in the midst of the market crisis, he ultimately forged ahead to San Francisco. After several months of odd jobs in construction and landscaping, Bob noticed one of his knees swell "to the size of a basketball" and was no longer able to support himself given the new disability. Given his lack of health insurance, he went to the county hospital for further workup of his knee.

Here is when my ears started to prick up.

He went on to describe how a young woman, identifying herself as a resident physician, had him change into a gown and reveal the swollen joint. After preliminary imaging and a thorough examination, the resident explained to Bob that the knee would have to be drained and likely injected with an anti-inflammatory medication. She described the risks and benefits of the procedure, had Bob sign a consent form and began preparing the clinic room for the minor procedure.

Bob, unaccustomed to playing the role of a patient in any hospital let alone a teaching hospital, was unfamiliar of the resident title and unaware of the significance it had in the spectrum of clinical training. Through further questioning, he soon discovered that this physician was only a few years out of medical school and had done only a handful of this type of knee procedure. Upon realizing this, he politely asked to postpone the procedure until a more experienced physician was available. Several hours later, a supervising physician drained Bob's knee, and he was discharged with a "brand new life."

Bob made sure to throw two thumbs up as he revealed the well-healed knee to me before driving off to his next customer.

The Conflict

Well, after seeing the last of Bob and his bum knee, his story stuck with me. At first I was angry over Bob's decision to deny care from a capable physician in training. I won't lie that I briefly felt that Bob's lack of insurance and admission to a teaching hospital waived his right to make the demands he had made.

But then I thought about Bob's situation. Here's a guy who could not afford an operator error on his injured knee given that he was living from paycheck to paycheck off physical labor. He had no experience with teaching hospitals and little understanding of the role of a resident physician. Furthermore, his insurance status should have had no place in limiting what questions and concerns he could voice with regard to his treatment. His decision to receive the most skilled care he could get was understandable.

And here lies the Resident's Dilemma: If all patients had the same resolution to bypass care from physicians-in-training, how are newly-minted doctors able to sufficiently train in clinical medicine?

What steps can be made to close the communication gap between patients unaccustomed to teaching hospitals and the house staff (i.e., resident and intern physicians) who care for them?

The Solution

There is undeniable room for improved communication when it comes to defining roles and setting expectations on how care is delivered in a teaching hospital.

To start, every member of a newly admitted patient's health care team should introduce themselves and their distinct roles as health care providers as early as possible in the patient's hospital stay.

There are often many members of a health care team in a teaching hospital and it is not uncommon for patients to get confused over titles and levels of medical expertise. The team should therefore write their names and roles on any available board in the patient's room and/or give out business cards to ensure transparency. Patient concerns about the level of training and clinical experience of providers should be answered as early as possible.

For patients like Bob who have little experience with teaching hospitals, there may be a need for additional educational interventions such as pamphlets or brief educational videos describing the fundamental role that resident physicians and medical students will play in their care prior to meeting the medical team.

Take-Home Point


Should I ever have the opportunity to ride with Bob again, I plan to ask him a few questions: If he was notified that he was in a teaching hospital prior to meeting the resident physician, would he be have been more amenable to having the procedure done by her? Does he plan to avoid teaching hospitals from now on knowing that most of the physicians are in the midst of their medical training? If he had to be treated by a team that included residents and medical students, what would make him most comfortable with the way his care was delivered?

In order to mitigate tales similar to Bob and his bum knee, teaching hospitals need to be more cognizant of the potential disconnect between patient expectations of care delivery and house staff need to provide direct patient care.

*The patient's demographic information in this article was changed to protect identity and assure anonymity.


**This article was originally written for The American Resident Project

4 Responses to Declining Care From Physicians-in-Training: The Resident’s Dilemma

  • Dennis says:

    Here is the problem with teaching hospitals. You’re right when you say most patients have little experience with teaching hospitals. Unfortunately, that’s the way physicians and these hospitals want it to be. I went into the hospital where my physician practiced for repair of an anal fistula. I had no idea of the processes or procedures and, when told to sign a document while lying naked under a hospital gown, I just signed it. You guessed it. It was a consent form that included allowing observers (undefined) to be present during my surgery.
    I was wheeled into an operating room with eleven people in it. Before I could question who these people were I was injected with versed and an epidural. I later asked for my medical records, including those from the operating room, and found out all the disgusting details. Without my INFORMED consent five nursing students got to observe a colonoscopy on me I was then put in the jackknife position, my buttocks were taped open and one of the student nurses got to do the prep of my buttocks and genitals. I was completely exposed during this entire procedure for all to see. I would never have known, thanks to the versed, had I not been awake long enough to feel the dread before I went out. That prompted me to investigate.

    The dirty little secret of the medical profession in general is that their idea of informed consent is to hold back the consent form until you’re a half hour away from surgery. Mr. Patient, please sign this 16 clause form which overrides any oral conversations you may have had with physicians and nurses. In this form you give up all rights to privacy, modesty and dignity while undergoing your surgery and while in the PACU.

    Don’t believe me? There is not one hospital or surgery center in Southern California that provides the consent form on their website. All the other forms needed to be filled out by the patient before surgery can be accessed from the web sites. But not the consent form. This is a morally repugnant practice and destroys any hope for patient/ provider trust. I know I will never trust the medical profession again to do what’s right. This is the same profession that thinks it’s okay to do pelvic exams on unconscious women without their permission and to do rectal/prostate exams on unconscious men going in for prostate surgery. This only ended as a result of legislation expressly forbidding it. The paternalistic attitudes of the medical profession persist to this day.

  • Dennis says:

    I welcome comments from the medical profession

  • A doctor says:

    I’ll comment Dennis. When you have a heart attack, please don’t come to a hospital; go to your auto mechanic. After all, just like auto mechanics learn by tinkering around on their car as a teenager, doctors learn everything they need to know by performing physical exams and surgeries on their friends and have no need for formal training. So I am sure your heart attack can be handled by the mechanic; it’s really just a clog in your heart’s fuel line and they fix those every day.

  • z says:

    I welcome comments from a doctor that arent condescending and unhelping while not addressing the issue.

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Brian Secemsky, M.D.

Medical writing for patients, students
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