How many times have you done this procedure, doc?

Questions such as this from proactive, increasingly knowledgeable patients place a physician on the horns of an ethical dilemma.  Although fellows are closely supervised and trained under a gradually increasing responsibility principle (based upon subjective evaluation), a time will come when there is no one available to back you up in the catheterization lab.

Fact: Someone has to be a physician’s first case of any given type. However, no one really wants to be that person.

Access to extensive medical information on the web has satiated some of our patient’s desire for information and expectations regarding medical procedures, which is a good thing. However, increased transparency and public awareness of medical errors has opened up a Pandora’s box regarding a physician’s skill level and experience.  The September 2012 issue of Men’s Health went as far as publishing peer reviewed data regarding the minimum numbers for particular procedures taken directly from medical journals. Specifically, coronary angioplasty and angiography minimums were reported as 50 and 82 procedures respectively.

Take home message: Hard numbers to meet your first month into fellowship.

Similar experience-responsibility disparities exist in commercial aviation.  However, in contradistinction to the patient-doctor encounter, passengers are neither cognizant of their captain’s flight hours nor face-to-face prior to boarding.  Further increasing the stakes, a new pilot’s first manifest could be 50 passengers or more. In response to public demand for greater safety, the airline industry was an early adopter of systems to increase reliable pilot performance including flight simulation technology and pre-flight checklists, which were quite effective in reducing fatal incidents for air travelers.  As a result, the latest National Safety Council in the U.S.A. calculated the lifetime odds of death for flying to be 1:7178 in 2008 compared to 1:98 for automobile deaths.

Interestingly, even experienced pilots are required scheduled simulation training to maintain their skills and prepare for rare-but-catastrophic events, which cannot be realistically produced in the air.  The auto industry, unique in their in inability to increase motorists’ skills, have been forced to develop safety technology to make the highways safer.

Reality check: Patients do not come with air bags or crash sensors.  Simulation and checklists are proven methods to increase safety.

Virtual reality simulation training programs allow students of all levels to gain familiarity with equipment selection, proficiency of the detailed steps for a given procedure as well as an awareness of the potential pitfalls and crucial moments in a safe environment. Furthermore, under experienced tutelage during practice, a modicum of fingertip finesse may be learned prior to laying hands upon their first patient.

While “ain’t nothing like the real thing” is unarguably the best way to learn any motor skill, having solid theoretical and practical experience makes the transition to live cases easier and might ameliorate the patient’s and the beginner’s shakes.

Max Berry is a vascular and interventional radiology fellow.

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  • Simon Whyte

    The anaesthesia community has long grappled with the concept of Number Needed for Competence. Obviously it varies between individuals & between skills. For me, the key to being able to reassure patients that the newly-appointed consultant/staff can do whatever skill it is, is a planned withdrawal of direct supervision during training. It has always struck me as bizarre that, in some training systems you can never do a case without the boss on your shoulder, right up to the last Friday of your training; and on Monday you come in & fly solo. I discuss w my trainees, at the start of each case, or each list, what the level of supervision remoteness is going to be: in the room; outside the OR door; in the coffee room; in my office, etc., etc..
    A few years ago the Association of Paediatric Anaesthetists tried to define minimum caseloads for various procedures that would be considered a sufficient critical mass of exposure to ensure competence. Then they surveyed their own consultant membership’s case numbers & found that even they weren’t doing ‘enough’ cases:-).

  • Ed

    As a professional
    pilot for nearly 30 years, your comparison of a physician performing his
    first unsupervised procedure on a patient is disingenuous at best for
    numerous reasons.

    1. You fail to
    mention every scheduled passenger flight has two pilots at the controls. If
    this is his/her first revenue flight, the other pilot will be highly
    experienced. Additionally, a Captain will likely spend a decade or more as a
    First Officer before he’s eligible for upgrade. That’s not counting the many
    years and countless thousands of hours proving their ability during training,
    check-rides, and day to day performance, every minute spent under the watchful eyes
    of others, just to be competitive for a First Officer position with a major
    airline.

    2. The
    professional and personal risks are not even remotely similar. Both pilots
    have a vested interest in the outcome; we arrive at the crash scene first. If
    we screw up, federal government experts will objectively examine
    every second of our lives beginning 48 hours prior to the incident. Diet,
    drugs, alcohol, sleep patterns, and physical health are all examined
    closely. Cockpit voice and flight data
    recorders will record every word and control input. Rightfully so, there is no
    hiding from the truth with any incident or accident in commercial aviation; the
    flying public deserves no less. Any
    errors are public knowledge and the professional career is effectively over. I
    think that contrasts sharply with how the medical profession handles their
    errors. While not entirely accurate, the public perception is the good ole boy
    network protecting their own; you have only yourselves to blame.

    3. Commercial
    pilots must satisfactorily complete a thorough physical exam every six months,
    administered by an objective Aviation Medical Examiner acting on behalf of the
    FAA. Additionally, we are subject to random drug and alcohol screening. This
    contrasts sharply with physician medical requirements or drug screening; to my
    knowledge, there are none. Additionally, commercial pilots, every six months, regardless
    of experience, must prove their ability to fly the jet during recurrent
    training. The simulators, otherwise, known as “Dial a Disaster” are
    administered by objective third parties, and not fun! If you fail any of the above, you lose your license and therefore the ability
    to make a living; that’s as it should be. Once again, the flying public
    deserves no less.

    You expect patients to bare their
    body and soul to you and your staff simply because of the MD at the end of your
    name; not any more. The medical profession could learn a lot from professional
    aviation; your choice is either proactive or reactive change. Your patients
    deserve no less and will demand it if necessary.

    Ed

  • Ed

    As a professional pilot for nearly 30 years, your comparison of a physician performing his
    first unsupervised procedure on a patient is disingenuous at best for numerous reasons.

    You fail to mention every scheduled passenger flight has two pilots at the controls. If
    this is his/her first revenue flight, the other pilot will be highly experienced. Additionally, a Captain will likely spend a decade or more as a First Officer before he’s eligible for upgrade. That’s not counting the many years and countless thousands of hours proving their ability during training, check-rides, and day to day performance, every minute spent under the watchful eyes of others, just to be competitive for a First Officer position with a major airline.

    The professional and personal risks are not even remotely similar. Both pilots have a vested
    interest in the outcome; we arrive at the crash scene first. If we screw up, federal government experts will objectively examine every second of our lives beginning 48 hours prior to the incident. Diet, drugs, alcohol, sleep patterns, and physical health are all examined closely. Cockpit voice and flight data recorders will record every word and control input. Rightfully so, there is no hiding from the truth with any incident or accident in commercial aviation; the flying public deserves no less. Any errors are public knowledge and the professional career is effectively over. I think that contrasts sharply with how the medical profession handles their errors. While not entirely accurate, the public perception is the good ole boy network protecting their own; you have only yourselves to blame.

    Commercial pilots must satisfactorily complete a thorough physical exam every six months, administered by an objective Aviation Medical Examiner acting on behalf of the FAA. Additionally, we are subject to random drug and alcohol screening. This contrasts sharply with physician medical requirements or drug screening; to my knowledge, there are none. Additionally, commercial pilots, every six months, regardless of experience, must prove their ability to fly the jet during recurrent
    training. The simulators, otherwise, known as “Dial a Disaster” are administered by objective third parties, and not fun! If you fail any of the above, you lose your license and therefore the ability to make a living; that’s as it should be. Once again, the flying public deserves no less.

    A passenger will never fly on a scheduled airline where one of the two pilots is not highly experienced. Unless a patient asks, this could be the first time a physician performs a particular
    procedure unsupervised.

    You expect patients to bare their body and soul to you and your staff simply because of the MD at the end of your name; not any more. The medical profession could learn a lot from professional
    aviation; your choice is either proactive or reactive change. Your patients deserve no less and will demand it if necessary.

    Ed