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The Elephant in the Room of #POCUS-guided (and other) Procedures

January 27, 2017 0 Comments

elephant in the room

Can I tell you a secret?

I did 5 years of residency, 2 years of family medicine in Canada (Quebec City) and 3 years of EM in the United States (Milwaukee). Both programs were really good and I got to do a variety of procedures and many of them. But even with all that training, I have done many more different types of procedures once in practice than I did in residency. That’s right. I have done many procedures for the first time once I was already in practice without the benefit of direct supervision. This includes procedures done with POCUS guidance and without. And I’m not alone. The reality is that this is the case for many, if not most emergency physicians.

If you consult your favorite procedure book (Roberts & Hedges, Reichman, etc.), you will note that there are literally hundreds of procedures in the scope of emergency medicine. It is simply not possible, even in the longest residencies on the planet, to have performed all of these procedures at least once while in training. Is this less than ideal? For sure. Should we be doing this? We often don’t have much choice. Although EM practice varies from town to city to province/state to country, in many cases, we are expected to do these procedures, by patients, by families, by nurses, and by consultants in other specialties. In some cases, patients may die if we do not act. In other cases, their suffering will be prolonged.

Even though we may not have performed all EM procedures during our training, we should still have the ability to perform any EM procedure. How do we come by that ability? There is a general knowledge base and a psychomotor set of skills that layers into our brains, special senses, and hands over the course of medical school and residency. How can we build on that base once in practice? When performing a procedure that is new to us, there are many strategies that can be employed to help us get over the hump. When a procedure is simple and low-risk, Google and YouTube might be all that one needs to supplement our core skill set. A deeper reading of a procedure book or article may be required for a procedure that is more involved or complex. A course is a good option, especially for a skill that is completely novel to us (e.g. airway course for video laryngoscopy).

But there is one skill or attribute that, although softer, is at least as important as the harder skills mentioned above for tackling a new procedure. That attribute is confidence. We can increase our knowledge by reading around a new medication (e.g. DOACs) or enhance our decision-making by learning about a new clinical decision instrument. We don’t need as much confidence to add this new information to our practices and augment the EM care that we provide. But to use a new procedure on a patient…that takes confidence!

The trouble is that our confidence is put to the test on a regular basis. It can really take a beating. This is especially true in medical school, residency, and early in our careers. In high school and university, many physicians had a 95% average…truly superior! However, if we maintain that average into our medical careers, that means we are wrong 1 out of 20 times! Not a recipe for maintaining confidence.

What is required to build and maintain confidence? Well, I am no expert on confidence. I don’t have a full set of solutions laid out. But it starts with recognition. It is important to put out there that (1) Emergency physicians perform new procedures (or new to them) once they are in practice and (2) Confidence is one of the attributes required to do so.

I will leave you with 2 links related to confidence that I found interesting: a post by a Dr Luckett (EM resident in Hamilton) who talks about confidence from the perspective of a female resident (equally useful for male MDs!), and one by Jeff Haden at www.inc.com who talks about perseverance from a military angle.

Discuss!

Steve

P.S. If you have the luxury of having more than one physician on shift at the same time, it gives you another option. It helps to have senior colleagues who, while on shift, can help out a younger physician. And, sometimes things are flipped. For novel procedures, it might be the young pup showing the old dog the new trick 😉

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