A Year Inside a Medical Residency: Part 2

With a few months under their belts, new doctors need confidence -- but not too much.

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One of our recent trainees --  I'll call him Pat -- was in November of his first year of residency. He had survived the first four months of the three-year training program. He'd already had two rotations on hospital wards and spent a month working in the intensive care unit. In learning to care for profoundly sick patients, he'd even had the opportunity to pronounce his first death, a formative experience for a medical trainee. With these sorts of experiences, though, can come an undue or premature sense of confidence.

Such was the case with Pat. As it often does, it came from learning the processes of care ahead of the essential clinical knowledge. He'd learned how to admit and discharge patients, how to write medical orders and work alongside nurses, aides, therapists, clerks, and pharmacists. He was beginning to feel he knew how the system ran. 

He'd learned some aspects of patient care, but at the four-month mark, he was certainly not yet ready to be declared a competent doctor. No one at this point is.

This confidence-knowledge gap is normal in medical trainees. Coping with stressful environments like residency necessitates that learners find some element of near-mastery in the early phases, or else the ego can be severely bruised.

Pat's ego was certainly intact. He was personable and gregarious, with a good sense of humor. Reviewing his file, I'd have been hard-pressed to find a fault. He was particularly praised in the realm of interpersonal communication.

One November day, though, Pat was working in the outpatient clinic. He was expected to see half a dozen patients over the course of the afternoon (intern schedules are light, building up slowly over time). His third patient was a woman who'd been discharged from the hospital three days prior. The only thing she needed was to have her central IV line removed. This would involve removing two skin stitches and pulling out the line.

A task such as "pulling a central line" is often considered intern-level stuff; anyone should be able to accomplish the task with basic instruction.

Pat approached the task a bit too cavalierly. He'd already taken out central lines in his stints on the wards and in the ICU, so he knew what to do. The problem is that his inflated self-confidence led him to take out the line without direct supervision. The faculty doctor supervising the clinic that afternoon took Pat's word that he could accomplish the task, erroneously failing at a minimum to have Pat enumerate the steps -- on account of his projected self-confidence.

Presented by

John Henning Schumann, MD, is a writer and physician based in Tulsa, Oklahoma. He runs the internal medicine residency program at the University of Oklahoma School of Community Medicine.

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