Clinical Conflicts: Should You Go Up Chain of Command?

Imagine finding a note in your ED patient's chart from a consultant, which recommends care that you believe is totally inappropriate. Should you quietly seethe, or report it to a higher-up?

The answer may depend on whether the emergency physician (EP) truly believes his or her patient's welfare is at significant risk. If this is the case, it may be important enough to escalate the issue to other members of the team, such as your medical director, chief nursing officer, or chief of staff, according to Randy Pilgrim, MD, FACEP, chief medical officer for the Schumacher Group in Lafayette, LA.

"Although it can be difficult, and may raise a number of relationship issues, it can also be a tremendous learning opportunity," says Pilgrim. "If it's the best thing you can do for the patient, it should be done."

In some lawsuits, plaintiff's attorneys have attempted to show that escalating an issue highlighted a problem with the patient's care. "If it's done properly, however, escalating an issue can show that parties acted responsibly and diligently," says Pilgrim.

Pilgrim indicates that he would much rather deal with a chart that has a clear, respectfully documented difference of opinion than one in which a difference of opinion went undocumented and wasn't addressed at the time of the patient's care.

"If you always keep the patient first, show that you cared, and communicate and act prudently, you have the best opportunity to defend the care that is now in question," says Pilgrim. "Without a clear patient-centered focus or good communication, cases are much more difficult to defend."

If a jury was to learn that you believed the patient was not being taken care of properly, and was possibly even endangered, says Hartmut Gross, MD, a professor of emergency medicine at Medical College of Georgia in Augusta, they would expect to hear that you went to the chief of staff or hospital administrator to seek resolution.

"Instead, you merely whined about it on the chart," says Gross. "If something bad happens subsequently, you'll be on the hook — not for error in medical practice per se, but deliberate neglect."


For more information, contact:

• Hartmut Gross, MD, Department of Emergency Medicine, Medical College of Georgia, Augusta. Phone: (706) 721-7144. E-mail:

• Randy Pilgrim, MD, FACEP, President and Chief Medical Officer, Schumacher Group, Lafayette, LA. Phone: (337) 354-1202. E-mail: