Anyone who knows me would never claim I am simple (at least not if they wanted to live). When I look at the world, or any given problem, medical or otherwise, I see a myriad of interconnected variables from diverse topics. Consequently, it is hard for me to call up compartmentalized information, but I have become quite skillful at dealing with dynamic situations or complex problems.
One of my former co-workers was not particularly valued by the company because of his incredible ability to explain very complex things in a way that was so simple, it seemed obvious and without any loss of accuracy.
In fact he once famously wrote the summary of a cardiac arrest call we were on simply: “Found patient pulseless apneic, followed Asystole protocols to termination of efforts.” Was the patient assessed? Obviously. IV initiated? Clearly. Intubated? (since efforts could not be terminated in that service without a tube, it must have been.) Proper doses of medications at proper times? For sure (they were spelled out in the protocol which we followed). Detect any reversible causes? Nope. Then we would have treated and documented them.
You simply cannot deny the brilliance.
Today, one of my friends still involved in the fire service posted a meme to Facebook that said “failing to train is training to fail.” I found this to be equally brilliantly simple as the code summary above. I see medicine fail to train every day. In fact, the only things medical providers train on regularly is CPR. Some studies have shown that is because medical providers are not very good at CPR. But it makes me wonder… Do medical providers do every other thing so well that studies show they do not need to train on it? I have my doubts. Even in specialty training, much of the “training” is indirectly supervised. So it is not really training, it is more like reviewing the act of figuring things out on your own, and often after a mistake. If somebody notices.
The failures of this system are readily visible and inevitable. People are doing whatever they thought of until either something goes wrong or somebody sees them do something wrong. What if nobody ever sees? What if the first time something goes wrong somebody dies or is seriously disabled?
Here is a real life example. I happened to be in a gynecology ward. In said ward was a patient who was in early childbearing age. She had complications of a laparoscopic surgery, which was converted to an open surgery, which resulted in what was reported to me as “excessive bleeding” and ultimately a unilateral salpingectomy. This of course prompted me to inquire; “What was the impetus to do exploratory surgery on somebody in her age group?” After all, I was there to learn, and I am not an expert at the field and could think of no epidemiological reason, so I really expected to hear some awesome clinical pearl nobody bothered to tell me or write in a book. I was then told that she had elevated cancer markers. So, being a bit naïve as to how “expert” specialists really are, I just blurted out “isn’t gonorrhea in the differential of elevated cancer markers?” At which point a very uncomfortable silence was observed. I thought I should make every effort to be quiet and disappear from the room and did. I later cornered one of the specialists and asked “I thought you were only supposed to use cancer markers to look for recurrence after surgical cure?” I was then let in on the fact that sometimes older doctors do not know all the latest guidelines in medicine because they are so comfortable with their routine; they will not change it, even if presented with evidence. They even have a standard line as to why new practices aren’t valid. “I have experience, and when you have been doing this as long as I have, you will understand.” This whispered dialog between me and the doctor filling me in continued with the question: “So why has she been in the hospital so long?” The answer? Because she was being carefully watch while undergoing treatment for PID and the attending physician who decided she needed exploratory surgery based on her elevated cancer markers thinks she will likely lose the other fallopian tube as well. My final question: “then why isn’t she on steroids?” After another uncomfortable silence, I decided I should not inquire further.
Now while anyone can make a one off mistake, have a bad day, not have enough coffee, etc, I noticed there was a pattern to this particular doctor. He is fully “trained” and licensed. Nobody ever corrects his practice. He is essentially doing what he taught and reinforced himself to do. He has trained to fail.
While tragic, it is not exactly scary. What is scary is I witness it every day, in every department I go to. I recall witnessing the same behavior when I worked in the US. I recall witnessing the same behavior when I worked in Afghanistan. This is not an isolated incident of an isolated doctor in an isolated country. This is everywhere I have been. I can only conclude in my pattern identification method of thinking, that this must be a problem everywhere.
So let us get all medical and diagnose the problem. Physicians are not training to succeed. They are not training in how to think. They are not training themselves to life-long learning and the desire for it. The ones who do are the exception, not the rule. They are mastering the system. 1. Get into medical school. 2. Get out of medical school. 3. Get into specialty choice. 4. Finish it and go do whatever. More often than not “whatever” is a set of behaviors and thought process akin to low level labor. Just like the old Duncan doughnuts commercial, “time to make the doughnuts.”
It is clear; we must train doctors to succeed. We cannot train them to follow a wrote set of behaviors with any level of effectiveness. We must train people how to think critically. How do we do that? Where do we start? Maybe scientific based entrance exams are not the way? Maybe quantitative analysis of study habits is not the way? I am still thinking on a solution, I have none. But the problem is rather obvious.
Medicine is failing to train, it is training to fail.