This is what lifelong learning in medicine should look like

He left a little early to stop by the cath lab to see his patient before her procedure.  Cordial “hellos,” “good mornings,” and “any last questions?” were mentioned before she signed her consent.  The team was working feverishly to prepare her for her procedure.  “Have you met the anesthesiologist yet?” was next, and almost on cue, the anesthesiologist arrived and took over for a bit.

He hurried upstairs to the conference room.  There, was an all-too-fattening array of welcoming donuts and bagels, a coffee and hot water dispenser, and a few remaining empty cups. This was the stuff of breakfast on more hurried days.  Still, a small cup of coffee was welcomed and poured quickly. Another nurse had arrived with him and he asked, “Can I pour you one?”  She accepted and they quickly made their way into the conference room after signing the attendance sheet.  They didn’t want to miss the start of the conference for that was sometimes the best part of the conference.

In a stroke of genius, the organizers of the cath conference quickly review the news of the week, both locally, nationally, and medical.  They even show wild things colleagues did the week before outside of conference, like flyboarding or a shot of a colleague holding a huge striped bass they caught the weekend before with their 8-year-old daughter.

Complaints about the design of the restrospective trial reviewing digoxin’s use for atrial fibrillation, sodium’s uncertain consumption recommendations were met with rolled eyes, and the possibility of transcaval retrograde transaortic valve replacement in patients with no other access was discussed, with a quick aside of direct translumbar aortic punctures and even direct left atrial punctures being performed by surgeons in earlier times.  In short, they shared the other side of themselves together, the reality of science, their humanness.

Then they shared cases.

The cases are not always pretty.  Some were tough cases, wonderful cases, cases no one had seen before.  They discuss the complicated social situations that bring even more complicated dynamics to the case.  They discuss the errors and the complications.  Importantly, they all understand this is a legally protected conference — a morbidity and mortality conference, if you will — a place where there are frank discussions about the right way to treat things and the wrong way, but a place that is supportive to those who have struggled, and incredibly helpful to those who still struggle with many challenges.  Administration hears about the problems doctors had with the lab equipment or staff or whatever, professionally.

And it’s the most popular conference in our hospital.  People of all ages and technical backgrounds are welcomed.  Old and young, cath lab staff, nurses, quality personnel, research staff, administrators, guest speakers, cardiologists and surgeons.  Everyone, that is, except industry or pharmaceutical folks.  This is, after all, the work of health care, not marketing.

At the end, they greeted, however briefly.  A quick question is asked.  A consult requested.  A research form signed.  Then off they went on their ways for another week to do their jobs.

This is lifelong learning as it should be: cordial, professional, collaborative, fulfilling, timely, up to date, and self-generated.  And it happens because it has to, not because it’s directed by a centralized bureaucratic money-making organization who claims they know what’s best for doctors and what’s best for society.

When doctors, nurses, technologists and health care teams learn this way it’s sustainable for a lifetime for one simple reason: Because it’s enjoyed.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

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  • Lucia Sommers

    The time-honored “place where there are frank discussions about the right way to treat things and the wrong way…. a place that is supportive to those who have struggled, and incredibly helpful to those who still struggle with many challenges” IS ‘sustainable’
    …’because it’s enjoyed.’

    So true! But I would humbly assert, it is also sustainable and enjoyable because learning WITH colleagues goes on there. Most of us will agree that the integration of one’s clinical experience with the current best evidence, taking into consideration the patient’s unique context/values/ dispositions, and doing all this, well aware of our own biases, is a tall order for the single clinician working alone… yet it happens on a daily basis, usually effortlessly, for the straightforward patient. When a patient is not straightforward, research tells us that physicians return to how they first learned clinical medical: they consult their colleagues. Regularly-scheduled gatherings such as Cath Conferences, M & M’s, and Tumor Boards have been hospital-based mainstays for this work, but, at least in the days before hospitalists, the doctors’ lounges or dining rooms were where you found colleagues to help you with
    perplexing, office cases. These colleagues would support you while you thought out-loud through the integration of clinical experience with the latest guidelines, all the while recognizing the unique family situation and your relationship with the patient. With 2-3 colleagues, sometimes over the course of a few days, you problem-solved, innovated, watchful-waited, or otherwise find ways to move through the uncertainties. Enjoyable, yes but also so necessary for good care.

    The need for such gathering places prompted us to create the Practice Inquiry CME Program at the University of California, San Francisco in 2005. Once or twice monthly, primary care physicians meet in their offices and clinics to present current individual patients that perplex or frustrate them. Together they search the literature for relevant evidence, examine decision making heuristics to reformulate strategies, return to the patient with new ideas, and follow the patient over time to recalibrate judgment and consider applicability of lessons learned to other patients in the practice. This approach and other small group, case-based learning methods, are described in our new book, “Clinical Uncertainty in Primary Care: The challenge of collaborative engagement.”( http://www.springer.com/medicine/book/978-1-4614-6811-0) Constituting ‘preventive M & M’s’ and ambulatory care ‘time-outs,’ we believe that these colleague collaborations are helping primary care generalists avoid errors (and burnout), engage in real-time lifelong learning, and restore some level of professional satisfaction.

    Surely there must be ways to recognize the time and energy clinicians put into gatherings such as these (as well as Cath Conferences, Tumor Boards, and M & M’s) and ‘accredit’ them so that they count’ for ‘certification.’ Should this come to pass, we could worry that a cumbersome, number-driven bureaucracy could grow up around these learning places and rob them of their intrinsic value. It would then be on our shoulders – those of us who care and maintain these places – to make sure that this doesn’t happen.

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