A few years ago……
Resus. 2300 hours. A man in his 60s is brought to the ED looking pretty sick.
He is normally fit and well but has had a cough for the last week, becoming breathless over the last 24-36 hours and finally collapsing at home. On arrival to the ED he is in full blown sepsis secondary to a nasty looking pneumonia. Obs? He looks sick!!! Heart rate is 110, BP 100/50, Resp rate 32, GCS 12. From memory gases were roughly…
- FiO2 60-80% (Hudson)
- pH 7.26
- pCO2 8.1
- pO2 7.3
- BXS -6
- Lactate 5.4
Fluids have been started, antibiotics given and preparations are made for the induction of anaesethesia to secure the airway. I draw up the following and brief Luka, my trainee on how I want him to give the drugs……
- Etomidate 20mg
- Suxamethonium 200mg
- Fentanyl 50mcg
- Metaraminol (just in case)
Luka pauses and asks…. ‘are you sure you want to give these drugs to that patient?’
[DDET “You dare to question me???”] So what’s all this about then? A junior…., a trainee for goodness sake questioning my judgement on how to induce anaesthesia in a critically ill septic patient. My choice of etmoidate was based on the sound knowledge that it is vastly superior to Thiopentone in cases where cardiovascular instability is expected!
Of course we now know that etomidate has fallen out of favour as an induction agent for septic patients owing to concerns about it’s adrenal suppression, but at the time this was the first I had heard of it. Luka basically knew more than me about the pharmacology, was more up to date and had a much better grasp of the literature at the time as he was putting a BestBet together.….., but he was the junior doc and I was the consultant. This was a challenge in an area where I felt that I fashioned myself as a bit of an expert, it caught me off guard.
This conversation, which I remember really well, was the primer, and subsequent driver for me pretty much abandoning etomidate as an induction agent. [/DDET]
[DDET On being told you are wrong…..] Let’s be honest. It does not feel good to be told that you’re wrong. Anyone who disbelieves this is either too stupid to realise when it’s happening or a liar….., or at least at first they are. However, seniority is an influence here and it’s potentially a rather dangerous one. As junior docs and medical students we get used to be being told where we are wrong, it’s part of the learning process and in many settings it’s almost an institutionalised process typified by the ‘pimping’ phenomena familiar to those on the wrong side of the atlantic ocean….(I suggest 1:15 as a great example 😉 )
Anyway, as time goes by and one becomes more senior and hopefuly wiser the incidence of being told you are ‘wrong’ gets less and less, but this is where trouble may be just around the corner. [/DDET]
[DDET “How does ‘the boss’ know when they are wrong?”] Is this a daft question? Perhaps it is, but do take note of the language, this not ‘if’ they are wrong but rather ‘when’.
You see there is an inevitability that no matter how senior you are, how clever you think you are or how many degrees, titles, honours you have. It doesn’t matter how good you were when you qualified, the company you keep or your past experiences. The bottom line is that medicine, particularly emergency medicine is a rapidly moving field and unless you are the sort of geek/nerd/weirdo that keeps up to date with everything at all times (a mythical clinician) then you will at any one time be ignorant of something.
I often return to the Donald Rumsfeld principle at this point. He spoke of things that we know that we don’t know and was riduculed for it in the press…., but he was right! I know that there are things that I don’t know
[DDET “The difficult box…”] If Rumsfeld was right we can think about our knowledge in a matrix that links our awareness with our abilities. This is commonly done to describe 4 domains.
- known:knowns – stuff we know we know
- known unknowns – stuff we know we don’t know (I can do a course/conference/development plan on this)
- unknown:knowns – stuff we don’t know we know (intuitive behaviour – a bit of gestalt perhaps)
- unknown:unknowns – The Rumsfeld box, and the really tricky one as there is no insight here. We are both ignorant of our ignorance and also incompetent. Clearly this is a really risky area as we will carry on here unless something moves us from here to known:unknowns (where we can do something about it).
[DDET “The Rumsfeld trainee.”] Having accepted that we are fallible and ignorant about things that we know nothing about then we really need to worry. We should embrace all things that move us out of this part of the matrix and towards competence and improvement……., but how?
As a trainee, with a curriculum and exam this is straightforward. There is a book with instructions to tell us what we should know. By comparing current knowledge with the curriculum the gaps are obvious. Not so as a consultant though…., not only is there no curriculum for being a consultant, but arguably consultants should be practicing at a level higher than that of a trainee exiting specialist training (Ed – oooh, controversial that one! Expect letters!). [/DDET]
[DDET “So how do we as consultants (well all of us really) gain insight into the unknown:unknown box?”] Let’s face it, it’s a challenge.
If you don’t know that you should be looking, then it is really rather hard to know where to look! We need to embrace others in helping us gain insight to those areas of practice that we cannot see and this is where I see trainees as a fantastic resource.
In the UK at least senior docs are usually fairly stable and historically have worked in small teams. This is a recipe for stagnation unless they actively seek development. Trainees on the other hand rotate around different departments, prepare for exams and are forced to keep up to date and attend regular teaching sessions. They are in the loop that the seniors may have fallen out of and are therefore a potentially really essential resource. [/DDET]
[DDET “Embracing dissent.”] So I hope that I have persuaded you that trainees who argue, correct and share their thoughts are really, really useful to the professional development of seniors.
However, the amazing learning that can be gained from trainees can only be realised if they feel willing and able to share. In my original case this was aided by Luka’s exceptional personality. A mix of laid back style, confidence and powerful intellect. He had no fear of sharing ideas in a non-confrontational way, but this is not something that comes easily to everyone. There are many reasons for this, many related to the concepts of authority gradient or power distance that prevent juniors from speaking up and correcting those that they perceive as their senior.
In the last few years I have learned so much from those who are technically my juniors, and now I am learning from a much wider community of peers through social media. Many of them are colleagues here on St.Emlyn’s and/or are now consultants here in Virchester. I raise my hat to all those people who have questioned my tweets, posts, blogs and thoughts. You are all an essential part of my learning and an essential driver for improving patient care in my hands.
This blog is to say thanks and to ask that it may long continue. So if you are a junior please challenge me and your seniors when you think you may know something new or different. For seniors please work on building an environment where you can be challenged. It’s good fun, it’s great learning and it improves patient care. [/DDET]
[DDET “So come on! Answer the question…”] OK, the question was how do you cope and that still deserves an answer….. These are my top tips, but you may have more.
- 1. Recognise that if a trainee tells you something new that’s great. It means they trust you enough to have that conversation in safety (so it’s a great thing for you).
- 2. Recognise that all clinicians are sources of learning for you.
- 3. If there is time to discuss it then seize the moment. If it’s a critical time sensitive case you may have to go with plan A and discuss it later (but make sure you do).
- 4. Know that you are ignorant of many things, sadly in many cases you do not know what these are, but your colleagues can help.
- 5. If you do learn something then share it. If you did not know something your trainee has shared with you then it’s pretty likely it’s the same for your colleagues. Find a way to share it and give them credit.
- 6. Say thank you and ask them to do it again in future.
If you’ve time then do pop over to Michelle Lin’s site and listen to Kathryn Shultz on being wrong. A great message there. [/DDET]
I’ve used the memory of Luka in this post because I still think of him and the contributions he made to Emergency Medicine. For me he had the characteristics of the best sort of trainee. Hardworking, honest, bright and dedicated to making EM better. He challenged me to be a better educator and to value the contributions of trainees as much as I do now. The subject of Etomidate came up at a point in my career when I was just starting to be being considered an established consultant, a little too far away from the trainees to be part of their social group, too far away to have ever worked with them at the same grade. It was and still is an interesting time.
The conversation described above was the last one I ever had with Luka. I, like all those who knew him still miss him and regret that we lost a colleague who would have been a great emergency and critical care physician.
Annual bike ride – coming up soon and everyone is welcome 🙂
[DDET “Tell me more – References and Stuff”] 1. Kathryn Shultz at Academic Life in Emergency Medicine
2. Pat Crosskerry is always worth a visit when thinking about medical error. Good paper from 2004 here. Cosby, K. S. and Croskerry, P. (2004), Profiles in Patient Safety: Authority Gradients in Medical Error. Academic Emergency Medicine, 11: 1341–1345. doi: 10.1197/j.aem.2004.07.005
3. My good friends Tony Bleetman and Trevor Dale co-authored this in the EMJ. Bleetman A, Sanusi S, Dale T, Brace S. Emerg Med J. 2012 May;29(5):389-93. doi: 10.1136/emj.2010.107698. Epub 2011 May 12. Human factors and error prevention in emergency medicine.
4. Being Wrong: Adventures on the margin of error. Kathryn Shultz [/DDET]