Saturday, October 15, 2011

The Steep Learning Curve

"In a hierarchy, every employee tends to rise to his level of incompetence."
-Laurence J. Peter

This week, I have had three separate conversations with three of my fellow interns about how incompetent we all feel.  The common theme is that it's like we're not really learning anything, and that we're getting worse (or at least not getting better).  I don't think that's really true, though.  The difference is that when we started residency four months ago, we were so ignorant about the practice of emergency medicine that we didn't even know how ignorant we really were.  Now we're almost equally as ignorant as we were then, but we know it.

Our eyes have been opened to our deficiencies on many levels.  We've seen what the upper level residents can do, and we don't measure up.  We struggle to handle the entire pod of patients when we're working one-on-one with an attending overnight.  We're starting to learn how to do procedures like central lines and lumbar punctures, but we're painfully slow at it.  We're not confident enough to argue when we come up with a plan for our patients and the attending wants to do something else.  We're too early in training to have developed our own practice style, and so we wind up doing something different for patients with similar chief complaints, depending on what that specific attending wants to do. 

For example, some attendings are very cautious and will CT a lot of people, while others lean away from doing very much testing in low-risk patients. It's a fine line to balance: do we want to risk missing a ruptured brain aneurysm in the 24-year-old with a new-onset headache if we don't do a head CT?  Bleeding in the brain is a potentially lethal condition that can be treated if caught early.  Or would we rather do the head CT and risk causing that patient to have brain cancer in twenty years because of excessive radiation exposure?  Not to mention that the cost of CT scanning every patient with a headache is prohibitive.  Or that every bed kept full with a non-sick patient who doesn't really need to be there means that a potentially sick patient is kept sitting out in the waiting room because no bed is available.

I don't have a good solution to this problem, and I suspect that the reason there is so much variation in attending practice is because they don't have a good answer for it, either.  Once again, we arrive at the conclusion that much of what we do in medicine is not based on good evidence.  Since I have too little experience to even rely on clinical acumen, it makes the judgment call next to impossible for me.  The daily struggle with this problem is yet one more thing that I was ignorant about before I started residency, and being aware of it now makes me feel even more incompetent as a physician.

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