Sunday, September 02, 2007

The cost of learning

They say you haven’t put in enough central subclavian lines until you’ve given someone a pneumothorax (an air leak into the chest). That’s when you find out how deep is too deep to plunge your needle. Likewise, you haven’t performed enough lumbar punctures until you’ve given someone a headache, intubations until you’ve chipped someone’s teeth, paracenteses (abdominal needle taps) until you’ve left someone with an ascites leak, or hysterectomies until you’ve punctured someone’s bladder. You haven’t learned how to administer fluids until you’ve put someone into pulmonary edema, or how to diurese someone until you’ve shut down his kidneys. The point being this: to become a competent doctor, you must hurt people along the way. Just as the evolution of a species occurs through the death of its less fit members, the evolution of a physician from inexperienced intern to practiced attending requires spilt blood. Residency, of course, is the prime time for this bloodletting, and the old piece of inside medical advice holds as true as ever: if you value your health, don’t get sick in July.

It’s a little bit depressing to start residency and think that before you finish, there will be scores of victims left in your wake, people who will entrust their care to you and for that trust have to pay a price. Sometimes the price will be small, such as a missed meal after a procedure when a late-tray was never ordered, and sometimes it will be significant, such as when inappropriate antibiotics were ordered for an infection. Rather than sulk, though, I think as residents we have to be vigilant and fight against the threat that our inexperience poses to our patients. In some areas, we are already probably less likely to make mistakes than our seniors; our awareness of our considerable limitations makes us more likely to pay extra attention to detail and to check our facts. The truly dangerous practitioner, it is often said, isn’t the one who knows that he doesn’t know something, but the one who thinks he knows something that he doesn’t. Residents, especially interns, are less susceptible to this particular pitfall, and so one of the best ways to avoid mistakes in residency is also one of the most natural: to ask for help when it is needed. It’s a terrible thing to harm a patient because you are too proud to seek help.

A second way of avoiding mistakes is by learning from those of others. That means being open and honest about mistakes and willing to share them to help others learn. If residency programs collected and distributed a monthly list of mistakes made by their residents, it could be an amazing teaching tool. Personally knowing the people involved would make the lessons all the more memorable.

My purpose here isn’t to methodically go through the ways of reducing medical errors, but simply to point out that, for residents who care, the mistakes of residency and their impact can be greatly lessened. Also, before I start scaring patients away from teaching hospitals, let me point out that there are many reasons why it’s good to have students, interns, residents, and fellows participating in your care. For one thing, our mere presence keeps the attendings on their toes; teaching concepts requires a higher clarity of thought than simply acting upon them. We like to ask questions, and having an additional bright, eager young mind going through the details of your medical case can’t be a bad thing. Less bound by time constraints, we will listen to your full story, and the substantial knowledge that we do possess, while hopelessly incomplete, at least is current. Some procedures we even perform better than attendings, because we do them more often. Truly, to request that no residents or students be involved in your care is to miss an opportunity for excellent care.

Like everyone else, I’ve had my fair share of blunders during residency. I’ve dropped people’s blood pressures, dried out their kidneys, and stuck them with needles to the point of absurdity. There were days when calling me a walking disaster would have been entirely appropriate. I’ve also saved lives, though, and for most of my patients, I know that their care was better because I was involved. Maybe I’m giving myself too much credit, but I think my patients would also attest that despite its fearful reputation, the cost of learning turns out to be surprisingly manageable.