Skill development

A couple of years ago, I was really worried by the whole ‘qualified and competent’ principle in the law that governs medical actions. Here, the law is that certain professions are allowed to do certain procedures (venipuncture, physical exam etc), but only if you are both ‘qualified’ (either a doctor/nurse/midwife/dentist or under supervision of one) and ‘competent’ (having had the correct training). The second part underlines your own responsibility in this, if you do a procedure that you are allowed to do but haven’t been trained in, you can’t hide behind your qualifications if something goes wrong. I certainly didn’t want to do things I was not allowed to, being quite scared of the disciplinary process that was drilled into us during lectures.

Now it’s quite amusing to read about my somewhat naive concerns. In medicine, there’s a lot of see one, do one, teach one going on. Atul Gawande writes about it in his book Complications and it is true: sometimes, patients serve as guinea pigs for medical students to learn procedures. I’ve contributed to it myself during my final internship by asking the medical students on their internal medicine rotation to draw blood for me on my patients. I remember how important it was for me to get lots of opportunities to draw blood in order to build a routine – and now I was passing on that privilege, knowing that sometimes, patients would have to be stuck twice (or more) to obtain a blood sample.

Actually, venepuncture is taught quite well in medical school – first on a plastic arm, then on a fellow student, then during one afternoon at the outpatient lab where patients are asked if they will allow the medical student to draw blood. So before I unleash a student on a patient, they will have done the procedure 5-6 times at least. For starting IV lines – another common medical student task – they were less well prepared, having done it once or twice or maybe thrice if a kind resident let them during the junior clerkships. However, most hospitals offer a kind of crash course, in which you get to place IV lines in the OR, so again, by the time you enter the ward, you’ll be somewhat familiar with the procedure.

However, a very important procedure, obtaining an arterial blood gas sample, isn’t taught in medical school at all. I was shown once how to do it during my week-long rotation on the Pulmonology ward. When the next ABG had to be drawn, the resident asked me to list the supplies, the steps and how I would explain it to the patient – then she sent on my way – give it a try, if it isn’t succesful, come and get me. Are you sure? I have never done this before. Yes, I’m sure you’ll do fine!

I went to the patient, explained the procedure, conveniently leaving out the fact that this would be the first time ever that I did it. Fortunately, I got my sample in one try. The week after, I coached another medical student through the steps, even though I’d done it only twice by then.

Did I throw away my principles? I could have refused and demanded more training. And still I trusted in my own ability and obeyed the order  given to me. Well, that’s not completely true. I trusted in my resident’s assessment of me. I knew the theory, I just had to gain the hands-on-skills. The point is, like Gawande also argues in his book, there is only one way to learn a procedure: by doing it. Until you actually try it, you can’t learn. Of course I always got help if necessary. Really. I’ve asked an attending to repeat my blood pressure measurements on a patient (the most basic of basic tasks) because I wasn’t sure of my readings. I felt really embarrassed but I knew I couldn’t stand the feeling of maybe having made a mistake.

Eventually, I also realized that someone needs to do the job. As a medical student, it’s easy to get your supervisor. I often went to get them when I couldn’t feel a vein, then I didn’t even try. As the supervisor, you need to call anesthesia to place an IV line, so you better try it at least a couple of times before you start the process of enticing them to come to the ward. So I’ve slowly grown used to starting a procedure even when not completely sure because if you won’t do it, eventually, it will be very difficult to get someone who will.

I haven’t touched much on the most important perspective: the patient’s view of all of this. I’ll come to that in later blog posts, but a vital aspect of medicine still is knowing your limits. I still hold myself to a ‘two tries’ limit – if I can’t place an iv/draw blood/ do an ABG in two tries, I’ll get help. But I will allow myself the space of thes two tries. Gradually, I noticed that I was now able to place IVs in more difficult to see veins – apparently, by taking the time and trying, I slowly built my skills repertoire.

For me, learning how to become a doctor was a big lesson in how to deal with uncertainties and my own insecurity. This example of ‘skill development’ is intended to illustrate one aspect of that learning process – and especially how difficult it is to stick to your principles in the daily reality of clinical practice. Some people become a confident doctor-persona overnight, in others it takes a little longer. And, most importantly: doctors aren’t saints. Doctors aren’t perfect and the process of how to learn isn’t perfect either. But we try, we go on, because we have to -personally, I couldn’t imagine doing something else than helping people.

For those who were curious: I finally learned how to do intramuscular injections during the primary care internship in year five. I don’t think that half of the vaccination was supposed to leak out after I’d removed the needle, but the doctor’s assistant who supervised me, pronounced it as a correct vaccination. I did two more injections, now supervised by the doctor herself and that was it.

And then I consolidated these skills by vaccinating a boatload of unsuspecting first year medical students during my social medicine internship. ‘You’ve done this before, haven’t you?’  ‘Yes’. ‘Great! Here are the vials and here are the syringes. I’ll stay for the first few injections to see whether you’ll be alright.’

I remember how a very insecure looking woman vaccinated me during my first year while an elderly man watched – an exact mirror of the situation I was in. Before she actually injected me, she practiced the ‘throwing a dart like movement’ a few times. I remember being a little bit put off but I didn’t dare to comment. In hindsight I think she was also a social medicine intern who hadn’t had much experience with intramuscular injections… 🙂

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