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Information for people contemplating
a career in emergency medicine and
other medical specialties

By Kevin Pezzi, MD


1. Thinking of leaving his ER residency
2. Every doctor could be a superb doctor
3. How PAs and nurse practitioners could outperform doctors

Q: So Dr. Pezzi, tell me if I need to consider leaving my residency.

I'm a resident in Emergency Medicine, halfway through training. It's odd, by now I would have thought that I'd be like my predecessors, with a firm grasp on my clinical and procedural skills, having earned the respect of at least some of the staff in the ED. Needless to say, I'm considering whether or not I belong in this specialty at all.

However, the other night, the following situation occurred. (some details fabricated, no names, should be HIPPA compliant, especially given the anonymity of this) 45-year-old male found down and seizing by family, with no history of seizures. History of cocaine abuse, family states that he'd been using lately. Presented via EMS, being Ambu-bagged, copious secretions from the mouth, still seizing, no IV access. I walk to the resuscitation room ahead of my attending (who graduated from our program this past June), look at his vitals, listen to the EMS report, and state, "This guy has been unconscious and seizing for over 30 minutes, and may have a head bleed given his cocaine use and 200+ systolic pressure. Let's get some IV access and get ready to intubate soon."

The entire resus room chimes in (no kidding, even the EMS guys), "Hey hey hey, hold on now doc, let's not get too excited."

Onto the stretcher, two nurses working for IV access. In walks the attending, who looks at the patient, and states, “Lets intubate.” To which, a flurry of respiratory therapists come dragging equipment and readying the laryngoscope and tube.

Still without IV access, we decide to EZ-IO® the patient. I drilled his leg, got it, and moved to the head of the bed for intubation (I'm the senior resident this night, so I get the “sick” patients). I take a look at this lanky man with a receded chin, jagged teeth, long skinny neck, and think, “anterior airway.” I ask respiratory to get out a Miller 4 blade in addition to the MAC 4 I usually use. I take a look with the MAC, no view whatsoever. I take a look with the Miller, and see the arytenoids and bottom of the cords, and try to pass the tube, but can't get it to go anteriorly. I reach for the bougie, when several nurses and respiratory guys say, “Come on, Dr. ______(attending), get in there and do this, he's been playing around enough.”

I've spent a total of one minute, with one desaturation to 89% (easy to bag, Ativan in), and I'm suddenly "playing around!" Is that a common experience?

Needless to say, I had multiple attendings take intubations and central lines from me, and I've asked around the other second-year residents, none of them have had that happen since early intern year. Am I to believe now that I am the most procedurally incompetent resident at our program? Does that mean that when I go out on my own, that I'll be killing patients by not being able to intubate? Or get secure central access (not everywhere I am looking uses EZ-IO)?

What's a resident to do, when they realize at 19 months into a program that several attendings and most nurses/techs/RT's don't trust your clinical judgment/skill level? Should I be looking at a specialty like Family Medicine where I can just do clinic-type work, and refer via ambulance anyone who looks sick to the ED?

I'm hoping for some insight, because that same attending when asked if I should bow out, said you are at the level of your peers, something I seriously doubt. Incidentally, that's what other attendings say, too: my performance eval is middle of the road, and no one is offering any helpful advice on how to improve (just, see more patients).

Answer by , MD: Just see more patients??? That's the typical response in residency programs because very few attendings therein know how to teach. The entire medical education process, from the first day of medical school to the last day of residency, is not optimally designed to convey knowledge or facilitate mastery of procedural skills. I could write a book on what's wrong with the medical education process and how it could be improved. The fact that most medical educators see no need to overhaul the system proves to me how out to lunch they are.

Medical educators would contend, “Oh, but we produce some of the best doctors in the world!” True, but that doesn't logically substantiate that they are optimally educating students and residents. The USA also produces many doctors who know far less than they should.

I am living proof. I graduated in the top 1% of my med school class, my residency director said I was the smartest resident they ever had, and one of my former bosses said I was the smartest doctor he ever met, BUT IN SPITE OF ALL THAT, I WAS A DANGER TO PATIENTS when I first became an attending, and despite how supposedly smart I was, I couldn't figure out why I sucked so much.

Now I know exactly why: because I had no self-confidence. For those of you who just spit the soft drink in your mouth across the room because that's radically at odds with my Internet image (as if that snapshot ever depicts anyone accurately), I explained my pathological lack of self-confidence in my blog. Scientific research demonstrated that anxiety impairs brainpower and performance—and believe me, when you have a purple patient dying in front of you and you can't call 911 because you are the END of 911, you'll be anxious.

I sucked at diagnosis, I sucked at treatment, I sucked at doing procedures. I could poke the spinal tap needle and poke and poke and poke until I finally found the correct spot.

Then something clicked in my brain and everything fell into place. I became so good at spinal taps I could hit the target on the first attempt even in the most challenging cases (obese, can't flex, elderly, bad back). I became so good the procedure became so fun I looked forward to doing them and frankly would have done them for free.

I also became much better at other procedures, easily doing ones that one of my bosses struck out doing, diagnosis, and treatment. In fact, the worse off you were, the happier I was to see you. I became so good at saving people in cardiac arrest (once going over 18 months without one death in a busy high-acuity ER in which I'd sometimes run three codes at the same time) that I ran out of the ER to go upstairs (where I had no malpractice coverage) to take over a code being botched by the residents. When I resigned from that place, the ER head nurse on my shift said he was sad to see me leave because I was the best diagnostician he ever met.

I still find that difficult to believe, but one thing is certain: I no longer sucked. I'd had brilliant educators, but none realized that the key to unlocking my potential wasn't to cram more facts in my head but to give me a spine.

I've seen how self-doubt impairs the performance of doctors, nurses, technicians, EMTs, and paramedics, especially in critical situations like codes. Much of this seems to come from ACLS courses that instill doubt and fear while making a fairly simple subject intimidatingly complex so the brains of smart people are paralyzed by anxiety.

The American medical education system is actually pathetic. Americans spend trillions of dollars each year—far more per person than any other nation. That massive spending camouflages deficiencies in healthcare practitioners. Without that money, on a level playing field financially (with each nation spending the same per person), American doctors wouldn't be the best, or even close to it. The American medical system burns money to partially compensate for its defects, analogous to a house with poor insulation burning more fuel to keep it warm during winter. Without that exorbitant spending on healthcare, Americans would be dying like flies and everyone would be cognizant of the problems and seeking to remedy them.

That's typical of the USA: we throw money at education in general, the military, government services, always getting little bang for our bucks, and we wonder why we're going broke? Sheesh!

The American educational system is optimized to financially benefit teachers and professors, not to impart the maximal amount of knowledge at the least possible cost in the least possible time. We're acutely aware of the energy efficiency of our homes and cars, but we're usually oblivious to educational efficiency even in years in which we personally spend considerably more on education than energy. Go figure.

In fact, most Americans are so poorly educated that they can't even properly valuate the economic benefit of higher education. Their illogic goes like this: college graduates make more money, so I'll make more money if I go to college. They are confusing correlation with causation; I analyzed this in another topic (Education increases income. Oh really?) and will later expound on that in my blog.

If college leaders weren't bereft of imagination and common sense, they could think of a way to dramatically slash costs while improving educational quality. Facebook's CEO Sheryl Sandberg has a remedy for poor education: “Why do we have lots of college lecturers around the world? Why do we not take the best person and show everyone?” Exactly! I advocated that many years ago.

Mastering procedural skills requires knowledge plus motor skills. Researchers have studied how to optimize motor skills but that knowledge doesn't filter down to most educators, explaining the amateurish “just see more patients” suggestion. By seeing more patients, you might eventually get it, or you might continue to reinforce whatever you're doing wrong, or at least not optimally.

Is there a better way to learn? You bet there is! The learning curve can be considerably shortened if you have a clear idea of what you're doing wrong (or not optimally). Once you know that, correcting it is easy.

I once had difficulty with various procedures (sorry for the repetition, but I later added the text in the above green block). To phrase this in shirtsleeve English, I sucked. I had enormous difficulty starting central lines, intubating, doing lumbar punctures (LPs), suturing, and coding patients. The brilliant advice from the geniuses who taught me (I'm being sarcastic) was to “just keep doing it, you'll get the hang of it.”

Yes, I did eventually master those things. As an attending, I could intubate patients my boss struck out on (example), get IV access when he could not, easily do LPs on even the most challenging cases, suture better than some plastic surgeons, save the lives of people other docs had given up on (example), and save almost every patient I coded (my longest hitting streak, so to speak, was successfully resuscitating every patient [even outside-the-hospital arrests] who coded in an 18-month period while I worked in a busy, high-acuity ER).

I eventually “got it,” but think of how many patients had less-than-ideal care in the meantime. The medical education system seems not to care about the patients it puts in the ground or otherwise botches the care of: they're just cattle who must suffer and die so doctors can learn.

Bullshit! Those are humans, and all humans deserve the best care. If there were no way to accelerate learning and acquisition of procedural skills, there would be no alternative other than chalking up their suffering as the price we must pay so others treated later do not.

However, because there are better ways, doing things the old way is unconscionable. It's an ethical abomination, yet educators are so hidebound and wedded to their antiquated, amateurish teaching methods that they don't perceive the need to change, nor are they willing to even try. I wonder what their primary defect is: are they that brainless (not smart enough to recognize what's wrong with the educational process) or are they that spineless (aware of the defects but too gutless to break from the pack)?

The history of medicine shows too much brainlessness and spinelessness. For example, see my blog posting on ridiculing new ideas in which I presented various examples, such as how the germ theory of disease was lambasted as quackery, to illustrate how society actively resists change and innovation even though it gives lip service to valuing it.

This is but part of a much bigger problem. The world is screwed up in myriad ways, and everyone with common sense perceives the need for change, yet the people who control this world really don't want things to change very much. They know the more things change, the greater the chance they won't remain on top, which is their primary objective. They'd rather be #1 in a third-rate system than #42,317 in a first-rate system.

In a blog post explaining how we could save our nation economically, I discussed how system justification motivates people to defend the status quo even when the system (such as a government, institution, or company) is inept, unjust, or corrupt and failing miserably. Thus, not only do the leaders want to stay on top, but the sheeple being screwed by them actively defend how they are being screwed!

If my ideas for reforming medical education and practice were implemented, every doctor could be superb. We could lop off not just the bottom half of the Bell curve, but the bottom 90%. I know what American doctors are thinking: “We're #1 amongst healthcare practitioners. We can rest on our laurels, even though what we're doing clearly isn't enough.”

American docs shouldn't be so complacent. By reforming medical practice alone, without reforming medical education, I could quickly enable PAs or nurse practitioners to outperform physicians even though the average PA or nurse practitioner has less aptitude and education than the average doctor. In fact, without any medical education whatsoever, I could make high school students outperform physicians.

In addition to providing much better medical care, my reformation would also save hundreds of billions of dollars per year. The need to provide better and less costly healthcare is obvious, yet American doctors complacently sit on their hands. They suffer from the Microsoft syndrome: thinking “We're #1, so we don't have to try very hard.” Logical people can easily spot glaring flaws in Microsoft products that persist year after year (even Bill Gates is exasperated by their junk), but their pathetically amateurish products remain that way because Microsoft is better at sitting on its hands than fixing problems that could be easily corrected. They have so much money and job security that they really don't care about the quality of their products or the customers exasperated by them. American doctors are similarly coasting in neutral when they should be going into overdrive to provide better healthcare at less cost before our nation goes broke trying to pay for it.

Suboptimal medical education never ends. I recently blogged about the obvious defects in continuing medical education (CME):

Sham CME (Continuing Medical Education)

Medscape CME problems

The secret pact of silence in medicine

I'll later add more articles to that series, because there is much more to say about that problem.

Now back to your situation. When the ER peanut gallery said, “Hey hey hey, hold on now doc, let's not get too excited,” they showed you the rocks in their heads. You were correct and they were wrong. ER staff sometimes subtly—and sometimes not so subtly—try to pressure doctors into giving less intensive care because it's easier on them. They're more apt to pressure residents as opposed to attendings, since the latter have more clout—at least in good hospitals in which administrators listen to docs who say, “This nurse (or whomever) has to go.”

I've worked in hospitals in which everyone got along as if we were one big happy family, and hospitals in which an infusion of young nurses with big heads infected it with a pugnacious attitude that began with nurses fighting doctors and ended with nurses fighting nurses. The ultimate problem in that case wasn't the young nurses (since many young people think they know more than they do), but the administration that wouldn't fire the most outrageously out of control nurses to set an example. Incidentally, that problem was eventually resolved when the hospital board fired the top brass at that hospital.

Not all mental illness resides in individuals; some groups, companies, hospitals, organizations, and even countries behave in ways suggesting they are profoundly poorly adapted to the real world. I suspect your hospital has more than a few workers who need counseling, a pink slip, or more mental horsepower.

So should the second-guessing emanating from those second-rate minds impel you to drop out of emergency medicine? No.

Since your attendings say your performance is middle-of-the-road, I'd do everything possible to improve, but I wouldn't drop out. In later topics (I need to get to work soon), I'll address how you could leave your attendings in the dust and even awe esteemed professors of medicine or surgery. However, that might not be enough to impress the peanut gallery; for them, you must use another tactic. Stay tuned for that, too.

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