the pain of medical education

Part of what I agreed to do when I agreed to work as the manager of
clinical services at the hospital was continuing medical education.
Now, considering that I'm the youngest doctor on the staff, and just
about the youngest medical person at the hospital, it feels a bit
presumptuous. One of the challenges of working together with other
doctors is what to do when your management is different from theirs;
trying to be sensitive to their management styles and yet not do any
harm to the patients. We basically all share a medical practice here at
the hospital, since we cover call for all of the wards when we take
call, but you don't get a chance to pick your colleagues like you would
in a private practice at home, and our training and experience levels
are highly variable, even when there's just a few of you. So you try
to hold your tongue when things are being done differently than the way
you'd do them, and you give your opinion when asked for it, and if
things seem like are being done very badly or they are dangerous for
patients, you try to speak up in a tactful way. And of course, teaching
people and calling their attention to medical errors that they've made
is also part of that job. It's a difficult job for a junior doctor to
do, though, especially in a small community where you work and live and
play together.
At home, the standard of care is much easier to determine, and it's
easier to show someone where they went wrong if they did something
wrong. Here, you have incomplete information, so it's usually just your
opinion that something was done wrong, but there are disturbing cases
that pop up along the way that make you worry that as a hospital we
aren't doing as good a job as we could to take care of people. I saw a
woman last night who presented with abdominal pain and said that she was
late on her period. The clinical officer had seen her that morning and
sent her home with treatment for giardia, but she came back with
worsening abdominal pain, localizing to the lower part of her belly.
The first on-call was notified, and she gave a set of verbal orders from
home and made arrangements to come see the patient in an hour or two. I
was rounding through the hospital before I left for the evening and
asked if there was anyone I should see. The nurse in the ward pointed
me to the woman, who was moaning on the bed. Her abdomen looked
distended, and I grabbed the ultrasound and found a tubal pregnancy with
about a liter of internal bleeding in her abdomen. We rushed her to the
OR, where her blood pressure was 70/40. I took out her ectopic
pregnancy and she did well, although she needed a blood transfusion.
Now, at home, it would be easy to go and yell at the clinical officer
who sent her home earlier that day, and the first on-call who didn't
come and see the patient when she was admitted. And, believe me, in
every training institution in America, that would happen, and they'd be
forced to stand up in front of a bunch of people and try to explain why
they screwed up. Here, however, it becomes a little harder, as the CO
didn't do a pregnancy test because we're running low on pregnancy tests,
so we're trying to save them, the blood pressure cuff is broken in the
outpatient department and we can't replace it yet, and he hasn't been
trained to do ultrasound. He's also just two months out of training.
And the first on-call had been on call for the past two nights because
we're short on RN's, and wanted to eat dinner before she came in to see
her, and knew that she'd already been seen once today. So when I go and
talk to them, it's hard to know exactly what to say, and how to say it.
Most of my attendings would have gotten angry, which I can understand,
because it's a simple solution to a complex problem, but I'm not sure
it's the right one. On the other hand, that fear of getting yelled at
has caused many lessons to stick in my head that otherwise probably
wouldn't have. As the most junior member of staff (in some ways; I'm
also curiously the most senior member of the doctor staff, by about a
month) it also feels inappropriate to be throwing my weight around like
that. So I approach these things prayerfully and carefully, and try to
choose my words well.