A medical intern is working on the inpatient wards at a busy community hospital. During rounds, the team evaluates a new patient admitted for worsening congestive heart failure. The patient's past medical history includes atherosclerotic coronary artery disease, diabetes mellitus, and pulmonary hypertension. Current medications include metformin, aspirin, and enalapril. On previous admissions, the patient admitted to using cocaine recreationally with friends and admits to the intern that his last use was today. The attending physician asks the intern to start the patient on propranolol for his heart condition; he will be expected to continue this medication following hospital discharge. After rounds, the intern recalls that during medical school she learned that beta adrenergic antagonists can interact poorly with cocaine. Which of the following actions by the intern is most appropriate?

Question

A medical intern is working on the inpatient wards at a busy community hospital.  During rounds, the team evaluates a new patient admitted for worsening congestive heart failure.  The patient's past medical history includes atherosclerotic coronary artery disease, diabetes mellitus, and pulmonary hypertension.  Current medications include metformin, aspirin, and enalapril.  On previous admissions, the patient admitted to using cocaine recreationally with friends and admits to the intern that his last use was today.  The attending physician asks the intern to start the patient on propranolol for his heart condition; he will be expected to continue this medication following hospital discharge.  After rounds, the intern recalls that during medical school she learned that beta adrenergic antagonists can interact poorly with cocaine.  Which of the following actions by the intern is most appropriate?

Quizplus · Accepted Answer

Interns on a medical team should not blindly follow the orders of attending physicians or physicians who have more seniority. As part of the educational process, it is essential to understand the clinical reasoning behind team members' decisions. It is in the best interest of both the intern and the patient to resolve potential problems before proceeding. This concept applies to the relationship between residents and attending physicians, physicians working in parallel (eg, anesthesiologist and surgeon), and medical students and other medical staff. The best approach is to respectfully discuss the issue directly with the attending physician and inquire why the decision was made. In this case, the attending physician may feel that the cardioprotective benefit of a beta-adrenergic antagonist outweighs the potential risk of an interaction with cocaine. (Choice A) It is unethical to blindly follow an order from an attending physician when there is concern about safety and patient care. The best course of action is to discuss the issue with the other physician and reach a consensus. (Choice B) Although seasoned nurses will have acquired a considerable amount of medical knowledge, it is not their job to decide between the differing opinions of 2 physicians. In addition, administering a medication that could have an adverse reaction is problematic, even if vital signs are being monitored. (Choice C) It is appropriate to explain the risks and benefits of the medication to the patient, who ultimately decides whether to take it. However, it is unprofessional to involve the patient before clarifying the rationale for the attending's recommendation. (Choice D) It is unprofessional to refuse to follow the suggestions of an attending physician without first consulting him or her (if the attending is directly responsible for care of the patient, as in this case). Educational objective: Physicians are ethically obligated to question orders that raise concern about potential harm to patients. Issues should initially be discussed directly with the physician who made the order and not involve ancillary staff.

A Medical Intern Is Working on the Inpatient Wards at a Busy