See one, do one, teach one.
It’s an old phrase in medicine, and it embodies a teaching philosophy that has been passed on for decades – observe, practice, then pass on the skill. During my third year medicine rotation, that expression was turned on its head once or twice.
Do one, see one, teach one.
I was asked to access a chemotherapy portacath – despite not having seen a port or the needles inserted into them. The intern dictated a list of supplies and told me the requisite steps, along with a couple of technical tips (namely, “it’s a big-ass needle, don’t stick yourself!”). I scurried off to the supply closet, eager to get started.
In many institutions, physicians are responsible only for placing central access catheters, which go into the large vessels of the neck and chest. Specialized nurses will place difficult IVs or peripherally inserted central catheters, and they also access ports. This allows these nurses to gain experience and develop immense skill in a small range of tasks. They truly become specialists, and they are far more proficient with those tasks than most physicians. However, this hospital didn’t have an IV therapy team, union contracts prevented nurses from dealing with most vascular access in a timely fashion, and these issues fell to the already overworked house-staff.
So, here I was, a medical student with less than a year of clinical experience. I was about to stick a large bore needle into a patient’s chest, aiming for a small device that carried silicone tubing straight into the heart. I had no frame of reference, no prior experience, for what I was doing. I had some understanding of the potential complications (infection, thrombosis, air embolism), but the intern didn’t review them formally with me.
Yet no one questioned the appropriateness of this situation.
My intern was happy to have another task checked off his seemingly endless to-do list. The nurse was glad to have vascular access in her patient without doing it herself. I was excited to actually be allowed to do something, anything (“I get to touch patients!”), though I definitely had some trepidation about the matter. And the patient was eager to just have the whole ordeal over with.
Of course, I struggled a little. I improvised a lot. I kept hearing a voice in the back of my head – “fake it till you make it”. And, eventually, both the patient and I survived the procedure relatively unscathed.
But would this situation be acceptable to me as a patient? Absolutely not. However, the hierarchy of medicine and my eagerness to be helpful prevented me from insisting on more appropriate conditions. I was too chicken to refuse, for fear of stirring up trouble, delaying patient care, and losing future opportunities.
Every doctor has to learn, and we all start with very little knowledge. We slowly gain knowledge and experience under supervision, an apprenticeship if you will, before we’re left to our own devices. But this should happen in a stepwise fashion, with incremental increases in latitude and responsibility. Instead, all too often, it’s haphazard, and junior trainees are left to sink or swim – along with their patients.