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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