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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Ina Fassbender / Reuters

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.

Pat failed to ascertain why the patient had the line in (a bleeding disorder, which had necessitated multiple transfusions). He also failed to check her most recent lab work, which would have made him be more alert to the possibility of bleeding (she had both a low platelet count and prolonged coagulation tests).

Shortly after Pat pulled out the patient's central line, she was being rushed back to the ICU. The floor of the room where Pat saw her was described as a "sea of blood." The patient required massive resuscitation with blood and fresh frozen plasma (which contains clotting factors). 

Pat learned a lesson that day, one that he's not likely to ever forget. A near-tragedy was averted, but his mistake added enormous suffering and medical cost to a vulnerable patient.

I always remember Pat's story around this time of year, as I meet with residents for semi-annual progress reports. I look to see that they're achieving milestones on their path to competence, and I also monitor for signs of over-confidence, especially among our interns, the least experienced group of trainees.

As with all learners, developmental paths of medical residents vary in trajectory and duration. Three years, the historical norm for an internal medicine residency, is more than enough for some, just right for most, and not nearly enough for others who will struggle to ever achieve proficiency.

So how do we know that the doctors we train are competent? Well, doctors need to have the intelligence and knowledge to diagnose and treat illness. They must be able to communicate, behave ethically, adapt to systems and work within them to make them better.

But objectively measuring a doctor's performance is still challenging. If you poll faculty physicians about what makes a competent doctor, they'll talk about diagnostic skill, beside manner, and reliability (i.e. professionalism). It's like the old Potter Stewart quote about obscenity: physician competence is hard to define, but "...I know it when I see it..."

This vagueness and an overall unease with the grading standards in general moved the governing bodies that accredit residency training programs to a newer, more objective and quantifiable evaluation system. Instead of merely assessing doctors on broad competencies like knowledge, communication, and professional qualities, we've now been given much longer lists of developmental milestones that more accurately reflect the numerous skills a competent physician should possess. The hope is that evaluating our doctors-in-training will be more comprehensive, fair, and objective. 

Fortunately, Pat learned from his mistake, as all physicians do. And so did the hospital, which shortly after adopted the now-ubiquitous checklists for procedures like taking out central lines. Like our new doctors-in-training, the facility and the system are integrated with continuously learning health care.