Ms N awoke with a feeling of dread. It was the same feeling she’d had for the past 2 months, ever since the 27-year-old nurse practitioner (NP) had been assigned a new supervising physician at the hospital where she worked.

Ms N had been working at the hospital for 8 months. It was her second full-time position since she graduated from her NP program; her first job had been with a solo general practitioner. While it was a good starting job and she liked the physician she worked with, Ms N eventually wanted something more challenging that offered a wider range of experience. When an NP position at the hospital became available, she jumped at the opportunity.

The hospital required new NPs to work rotations in different departments during their first year. Ms N’s first rotation in the gastroenterology department was challenging but interesting. Her second, on the maternity floor, was primarily uplifting. In both cases, her supervising physicians had been kind and were generous with their advice and counsel. The physicians in both instances welcomed Ms N’s questions and encouraged her curiosity. But her latest rotation in the emergency department (ED) was quite different.

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Dr D was Ms N’s supervisor in the ED.  He was a brusque and short-tempered 59-year-old who had a good reputation as a physician. Ms N had initially been looking forward to working with him, as she imagined that she would learn a great deal. However, her excitement soon turned to dread as she spent more time with him. Although polite to patients, the physician was extremely short with Ms N. He made it clear by the second day that he was not interested in conversing with her, and he did not appreciate what he considered unnecessary questions. Within a few days of working with him, Ms N’s excitement had diminished, and she began feeling trepidation at work. She spoke with some coworkers about the situation and discovered that no one liked working with Dr D, and everyone knew it was better to not interrupt or question him. As the months passed, Ms N had largely succeeded in keeping a low profile with Dr D, but she couldn’t wait to get out of the ED.

One afternoon a patient was brought into the ED with a knee injury. Mr G was a 40-year-old married man  with 4 small children. He was employed as an armed security guard at a federal building and sustained an injury while working.  According to the account he gave to the triage nurse, Mr G had been walking over a barrier that was lying in the ground when the barrier was activated by a coworker. The barrier went up and hoisted Mr G into the air, causing his knee to twist. Mr G was then trapped in the barrier. When Ms N examined the patient, he appeared to be in a great deal of pain; however, he tried to downplay the severity of the injury.

Ms N sent Mr G for a series of radiographs and established a list of differential diagnoses, including knee sprain, broken or fractured knee, and knee dislocation. When the radiograph results came back, Ms N was able to eliminate a broken or fractured knee. When Dr D came to examine the patient, he snatched the radiographs and file from Ms N and asked the patient a few questions. “Knee sprain,” the physician barked to Ms N. “Discharge him.”

Ms N opened her mouth to ask about the possible diagnosis of dislocated kneecap but then changed her mind. Dr D had years of experience, had just seen the patient, and had looked at the patient’s radiographs. There was nothing she could suggest that he wouldn’t have already considered. She believed that it wasn’t worth risking his wrath for such an unlikely possibility. The patient was discharged after having spent 2 hours in the ED.

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Two days later, the patient returned to the ED. He was found to have no pulse in his foot and was diagnosed with a knee dislocation that caused an injury to his popliteal artery. The patient required an above-the-knee leg amputation.

The patient’s family encouraged him to speak with a plaintiff’s malpractice attorney. After looking at the medical records, the attorney agreed to take the case and sued the hospital and the treating clinicians. Ms N was horrified to learn that she was part of a lawsuit.