Wednesday, January 7, 2009

Why not to be afraid of residents, part I

I am often told by people, sometimes in a tone of pride, that when they require care at the hospital "I always have the attending see me, without the resident." Or else: "I don't want to have a resident operating on me, you know; I want someone with real experience." Sometimes these confidences were relayed to me when I was in the middle of my own residency; not exactly a shot in the arm in terms of confidence, I can tell you. The thinking behind this--so far as one can accurately label it as "thinking"--is that residents are inexperienced and attendings are seasoned, and you don't want to be practice material for some greenhorn, now do you? Let someone else be fodder for klutzy residents (as in: poor people in city hospitals).

Perhaps. I can't deny that residents do not possess the full complement of skills of a well-seasoned attending (at least in theory). I also can't deny that it takes years of day-in day-out work to attain that skill set. But while leafing through Malcolm Gladwell's very good new book Outliers I read a passage that sheds some light on the issue, starting with the same premise (more experienced people should be in command) and arrives at a strikingly different conclusion (that's not necessarily better for your health). Gladwell spends a chapter dissecting various plane crashes in recent history. He discusses "mitigation," the process of engaging in deferential speech toward a superior, hinting with various levels of subtlety when inferiors believe the superior is making an error, and makes the following remarkable observation:

"Mitigation explains one of the great anomalies of plane crashes. In commercial airlines, captains and first officers split the flying duties equally. But historically, crashes have been far more likely to happen when the captain is in the 'flying seat.' At first that seems to make no sense, since the captain is almost always the pilot with the most experience...planes are safer when the least experienced person is flying, because it means the second pilot [the superior] isn't going to be afraid to speak up." [my emphasis]

I do not know for certain if there is any way that medical errors can be tracked in such a manner (likely not). But I could see how you could substitute "attending" for "captain," and "resident" for "first officer," and arrive at similar conclusions. That holds especially true for the uber-deferential world of the operating room, with surgery's typically rigid hierarchical culture. Worth considering next time you think yourself above the care of a resident (and that it's the hoi polloi who deserve such scraps). Or rather, when one thinks oneself is above such considerations--because you wouldn't ever venture near such a thought, would you?


  1. I have a dim memory of some research on surgical errors associated with the 'style' of the surgeon, in which lesser beings were more or less reluctant to call attention to potential errors in the making depending on whether the surgeon was less or more authoritarian, respectively. Or something like that: the neuron that was responsible for remembering the particulars of that bit of info is asleep on duty.

  2. Gack! I tied myself in syntactic knots and reversed the relationship: Underlings were less likely to call attention to potential errors in the making if the surgeon was more authoritarian.