Pediatric Residency Day One…..
On July 1st, I found myself in a very unique position. I arrived for work at 7 AM and found waiting for me two eager but nervous new residents ready to work, and more importantly to learn. And six other interns were scurrying around somewhere else in the facility or at their continuity clinic across town. This was day number one of a brand new pediatric residency program and it is a big deal. New programs, especially in pediatrics, are rare occurrences and I am lucky to have practically stumbled into being a part of this one.
I’ve worked with hundreds of residents at other institutions in the past but this is different. My role in this program is much more significant in that the majority of their time spent learning how to take care of hospitalized pediatric patients will be with me. In addition to their time on the inpatient units, I will also be giving numerous resident lectures throughout the year on topics of my own choosing. These eight young doctors, and the many future classes yet to come if things go according to plan, will be heavily influenced by what I have to teach them.
I would be lying if I said that the thought of eight new residents per year looking to me for guidance isn’t satisfying to my ego. It would be for anyone. But I’ve spent a lot of time thinking about this and have come to the realization that this opportunity is not about personal satisfaction. I am taking this more seriously than anything I’ve ever done in my career thus far.
Every day I look around me and am mystified at how little critical thinking plays a role in our lives. I’ve said it before, and I’ll say it again now, it is as if we live in a society that has allowed reason to take a backseat to emotion and critical thinking to be subservient to magical thinking. It is painfully clear to me that in this country science is still looked upon by many with fascination, which is good, but also by a growing number of people with disdain. Some even actively oppose it. And even many of those who do recognize the power of the scientific process to unravel the mysteries of the natural world seem to believe that scientific thinking and skepticism are activities for scientists and geeks like me rather than as a useful skill that can be acquired and put to good use by everyone.
In the world of medicine, where I spend the majority of my time, I see this frequently despite the fact that this world is populated by men and women who have devoted their lives to translating scientific progress into bettering the lives of others. I see this despite the fact that many who also exist in this world have educational backgrounds heavily influenced by science. As medical professionals, most of us are not scientists but, as stated above, are responsible for taking science and making it work in the real world. Unfortunately, that doesn’t always equate to a medical professional thinking scientifically or acting rationally when caring for patients. Not that being an actual scientist is a foolproof means of avoiding the path to irrational thinking. That path is well worn and a much easier route to take for anyone regardless of whether or not they have a PhD. History is full of examples of brilliant scientists checking their reason at the door.
I am taking my role as primary educator for these new interns seriously, not because it is a leap forward in my career, but because it is a privilege. These young doctors deserve to have their education taken seriously, and more importantly, so do their future patients. And one day, each of these interns will have opportunities to educate others. This includes future generations of residents, other medical professionals such as nurses, patients, parents, and the public. The medical knowledge I share with them, or more importantly the skeptical mindset that I will attempt to instill in them, might over time be carried over to thousands of others, like a reverse pyramid scheme where information goes down instead of money going up. It is exhilarating while at the same time it is quite humbling.
One of my favorite expressions, and one which I wish I could claim credit for, is that the three most dangerous words in medicine are “In my experience”. When we begin to rely too heavily on our own experience, we are perhaps too far along the path of unreason to ever find our way back. Using experience to guide medical practice is risky because the devices that have been installed, maintained, and periodically updated by evolution to interpret reality, as amazing as our human brains can be, are flawed. Experience, although a useful if not clumsy means of discovering where to focus the much more powerful lens of science, steers us in the wrong direction much more often than it leads to advancements in our understanding. I owe these residents better than my personal experience.
During rounds on day one, after introducing the new interns to the nursing staff and highlighting the concept of the team as an approach to medical care, I went over a few ground rules and personal promises (admittedly a little better fleshed out here):
- You will never be told to do something because I said so or because that is the way I do things. I expect you to support your management decisions as you should expect me to support mine, not with experience but with evidence. If no evidence is available, we will support our decisions with plausibility at the very least. This is the very essence of science-based medicine.
- Expect to be questioned, and prepare for it. I expect to be questioned by you. The only bad question is the one you don’t ask. Do not be afraid to be wrong or to reveal that you need help. Do not be afraid to ask for an explanation because you didn’t get it the first time. This is not the playground in 3rd grade and you will not be made to feel stupid or embarrassed for making a mistake or not grasping a complicated concept the first time it comes up. Expect to be questioned by patients and their familes. In fact, encourage it.
- There will be times when we come to two different conclusions regarding a patient’s care. I do not outrank you. My experience, although it may lead me to think differently about a particular situation or lead me down a different diagnostic path, ultimately should not play a role in whether or not my decision constitutes the best approach to a patient’s care. If you can back it up better than I can, we go with your plan.
- The approach that makes the fewest assumptions is likely the best approach. For example, if you admit a 2-year-old with multiple fractures and bruises, don’t assume that someone else thought about or ruled out child abuse. If you admit a 5-month-old with fever and dirty urine, don’t assume that someone else sent a urine culture. Don’t assume that the dose for antibiotics ordered by another doctor, even me, especially me is correct. Do assume that you are the only person responsible for caring for each patient and act accordingly. (Sort of a modified Occam’s Razor)
- Don’t poke any skunks. Ordering labs or imaging that you don’t really need will rarely result in a positive outcome and has potential for many negative consequences.
- Always strive to be aware of your own limitations, in both medical knowledge and in thinking. We are all biased in many ways, often without realizing it, and this can affect our medical practice. For example, when you admitted that 15-year-old with fever and sore throat, why did you look up diagnostic criteria for Lemierre’s Disease and order a CT scan of his neck when his presentation is much more likely to be a result of infectious mononucleosis or strep throat? Was it because you had a patient last week with Lemierre’s who you had to transfer to the PICU or because it truly deserved a high spot in the differential? The hoof beats of zebras sound exactly like those of horses, but which do you really expect to come see galloping around the corner.
- Things are not crazier during a full moon! And I’ve got the evidence to prove it.
- Wikipedia and Google are good places to start but would you tell the parent of an ill child that Wikipedia recommends an infusion of IVIG?
- If you are only going to remember one thing, remember to respect the nurses and to learn from them. And remember to share your rapidly expanding fund of knowledge with them in a respectful and constructive way.
- When in doubt, about anything, call your attending. Do not worry about bothering or annoying us. Worry about taking care of the patients in the best way possible because that is your ultimate responsibility.
My goal, lofty as it may be, is that every resident graduating from this program will be armed with the skills to practice medicine safely, effectively, and skeptically. With the ubiquitous nature of the internet, the near entirety of medical knowledge is at almost everyone’s fingertips. To be a good doctor, it is becoming less important that our brains are stuffed with medical knowledge because of that ease of accessing information. But what is becoming increasingly vital as our rapidly progressing understanding results in staggering complexity, is the ability to unravel that complexity and provide care based on solid evidence while avoiding the numerous errors in thinking and emotion based biases that we are so prone to. Nobody is perfect, certainly not me, but I promise to do my best to assist these new physicians in fulfilling their potential.