Are the doctors of tomorrow going to sink or swim?

We finally broke down and bought floaties. The kids played for a few days in the shallows, but since neither of them are yet proficient swimmers, they dared not wander into deeper waters. Each day they watched as younger kids scooted around the pool wearing wing like contraptions colored with cartoon characters.

I never liked the idea of floaties. Much better, I thought, to let them struggle and build on the lessons from last summer. But as the days went on, we realized that they would have more fun with a little independence.

The kids were overjoyed when we fit the balloon like apparatus over their arms. They were released from their own physical restraints.

All impetus to grow and learn was gone.

***

The oversized spinal needle gleemed as I held it up before attaching the 50cc syringe. I had worked my way through the pulseless electrical activity algorithm and finally came to pericardial tamponade.

The hustle and bustle of the VA was oddly quiet at midnight. A little over a year ago I was a medical student, now I was the most senior physician in house. I was about to plunge a large needle below the xiphoid process and angle up toward the heart. Then I would pull back and advance slowly.

The blood squirted into the syringe like an avalanche of red water. I looked up at the monitor and noticed that the rhythm converted to sinus. Moments later, I palpated a pulse when groping for the carotid artery.

My patient would code a few more times that night before eventually succumbing. Each time, the interns and I would race to the bedside and commence resuscitative efforts. There were no attendings, no seniors residents, and no floaties.

***

A decade later, medical training has changed. The transition from learner to decision maker is more gradual. By the third year of training, many residents have never run a code by themselves.

The problem with flotation devices is that they allow you to survive when you are a weak swimmer. They do not help you develop the skills you will need to keep your head above water. They are a crutch. Life saving in the beginning, deadly in the long run.

We need to clarify this duality in medical education. Careful oversight has to be balanced with incremental decision making and independence.

At some point or another, the floaties have to come off.

Are the doctors of tomorrow going to know how to swim?

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • Brian Clay

    While I understand your reticence, this is not the appropriate analogy.  One should imagine not whether people should attempt to swim without support, but whether we should allow them to serve as lifeguards without oversight.

  • Nehemiah Spencer

    yeah, I think this oversimplfies things a bit. While I often like the articles on here, I don’t think this is accurate representation of medical training. I do think medical training could be significantly improved, but not just by a sink-or-swim approach.

    Even floaties can be slowly deflated to encourage progressively, incrementally more independent swimming. 

  • nikolausrimsky

    Old people always complain about the movement away from the so-called “good old glory days.” It makes me yawn. The kids will be alright.

  • http://www.thehappymd.com/ Dike Drummond MD

    Really Jordan … you think tapping pericardial tamponade by yourself with nary an attending or senior resident in sight is GOOD THING?

    Wow … I have rarely seen such a stellar job of black and whiting an issue that is on a massive grey continuum.

    There is a balance to be struck between the gladiator style survival training of the past that lead to half of all residents and med students being burned out at some phase in their training … not to mention the well documented increases in medical errors associated with ill supervised residents working 120 hour weeks …
    And
    A less taxing work schedule and a more logical teaching progression than the “see one, do one, teach one” training methods of old.

    And Yes …. the doctors of the future will know what to do when the time comes and they will kill less patients (and we will lose less qualified physicians in training) along the way.

    Look in the mirror and ask yourself this. If you had not been so traumatized by your training … felt like it was something you had to survive … would you feel this way. Most of this kind of emotion comes from the “well I had to go through that living hell and you should too if we are both going to have an MD behind our name”. Check it out. I am pretty sure you really aren’t worried about “floaties” and such.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • PoliticallyIncorrectMD

    Jordan,
    Kudos to you!  I agree with you completely.  It is now fashionable to justify less rigorous medical training in the name of patients’ safety.  This approach though hypocritical, is politically appealing.  Unfortunately, the data suggest the opposite.  Massive 2009 VA study demonstrated no improvement in patients’ safety after residents’ hours were restricted.   In addition, new physicians fail to learn making decisions and taking responsibility.  People who criticize you much rather stand in the corner of the patient’s room having academic discussion, while you will be saving somebody’s life.  We all need more physicians like you.  Thank you and congratulations.

  • http://twitter.com/KarenSibertMD Karen Sibert MD

    When is the best time to be allowed to make a mistake?  Should you be closely watched every minute until you’re completely on your own? I don’t think so.  We’re overseeing trainees too closely because of zero tolerance for mistakes these days, and the threat of lawsuits.  I’d hate to be a graduating resident today, with so little experience at flying solo.  http://apennedpoint.com/when-is-the-best-time-for-mistakes/#more-276

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