Examkin

Question

Difficulty: HardInterprofessional Teamwork and Conflict Resolution

A 62-year-old man is admitted to the telemetry unit for treatment of an acute pulmonary embolism and is currently receiving a continuous unfractionated heparin infusion. During the night shift, the cross-covering first-year internal medicine resident is urgently paged by the bedside nurse, who reports that the patient has developed acute-onset right-sided weakness and a facial droop over the past 20 minutes. The resident evaluates the patient, confirms the new focal neurological deficits, and suspects an acute ischemic stroke. The resident immediately contacts the on-call neurology attending physician. After hearing the presentation, the neurologist states, 'This is likely a recrudescence of an old deficit. Order a magnetic resonance imaging scan for tomorrow morning. I am not coming in for this.' The resident reviews the chart and finds no prior history of cerebrovascular accidents. The resident expresses concern, stating, 'I am concerned that this is a new acute stroke requiring immediate evaluation, as the patient has no prior neurological history.' The neurologist replies, 'My clinical judgment stands. Do not page me about this patient again tonight,' and hangs up the phone.

Which of the following is the most appropriate next step for the resident to ensure patient safety?

  1. Contact the on-call internal medicine attending physician to escalate the clinical concernAnswer
  2. B
    Discontinue the continuous heparin infusion and order an emergent non-contrast head computed tomography
  3. C
    Document the neurologist's recommendations in the electronic health record and perform hourly neurological assessments
  4. D
    Initiate a transfer to the intensive care unit for closer hemodynamic and neurological monitoring
  5. E
    Assume a diagnosis of functional neurological symptom disorder and request an emergency psychiatric consultation

Answer

The most appropriate next step is to contact the on-call internal medicine attending physician to escalate the clinical concern.
The correct action is to contact the on-call internal medicine attending physician. High-reliability organizations prioritize patient safety over hierarchical deference. When a team member voices a critical safety concern and it is dismissed or ignored, they must persist. The 'Two-Challenge Rule' dictates that a concern must be voiced at least twice. Because the neurologist explicitly forbade further contact, the resident is blocked from completing a direct challenge and must immediately utilize the formal chain of command. The resident's supervising attending is the appropriate person to mediate an attending-to-attending clinical dispute and secure emergent care for the patient.

Step-by-Step Solution

1
Identify the patient safety threat
The patient has signs of an acute ischemic stroke within the treatment window, but the required consultant is refusing to evaluate the patient.
Recognizing a time-sensitive emergency is the first step in advocating for patient safety.
2
Evaluate the status of interprofessional communication
The resident attempted to use advocacy and assertion (similar to the Two-Challenge Rule) by voicing clear concern, but the neurologist actively blocked further communication ('Do not page me').
Standard conflict resolution tools (like CUS or the Two-Challenge Rule) require an open channel. When the channel is closed by a superior, peer-to-peer or subordinate-to-superior communication has failed.
3
Determine the appropriate escalation pathway
The resident must activate the hospital's formal chain of command by contacting their direct supervisor (the internal medicine attending).
Escalation to the supervising attending ensures that a physician with equal hierarchical standing (attending-to-attending) can intervene to secure necessary patient care.

Key Concept

Chain of Command Escalation in Medical Conflicts
Rate this question

Topics

Interprofessional Teamwork and Conflict Resolution

More questions from this topic