The Corpus Callosum

Dr. Richard
Friedman
, professor of psychiatry at Weill Medical College of
Cornell University, has an article in the New York Times.  In it,
he claims that reforms in medical residency training may be leaving
young doctors “a little more hesitant and uncertain than you might
like.” 

At first I was hesitant to write about it, because I was uncertain as
to what point he is trying to make.  But then I decided to go
ahead.

href="http://www.nytimes.com/2009/03/17/health/17mind.html?pagewanted=print">Accepting
the Risks in Creating Confident Doctors

By RICHARD A. FRIEDMAN, M.D.
Published: March 16, 2009

…Just as we want psychiatrists in training to become
confident and knowledgeable, we also have to protect patients from the
errors that result from their inexperience.

But one day, our residents will leave the protective cocoon of training
and go out on their own. Have we struck the right balance among
education and training and patient safety to produce psychiatrists who
can function independently? I’m not sure we have…

I guess I am not alone in being unsure. 

Dr. Friedman mentions that medical residents are now limited to working
no more than 80 hours per week, with shifts not to exceed 30
hours.  Consideration is being given to a recommendation to limit
shifts to a measly 16 hours.  The rationale is that such limits
might improve patient safety.  (Note that the fact that it would
be more humane, is not considered to be relevant.)

The fact is that all physicians in training pose an
inherent risk to patients. We should do everything we can to minimize
this risk but recognize that it may impair physicians’ self-confidence.

This I can quibble with, with confidence.  All physicians,
regardless of whether they are in training, pose a risk to
patients. 

He goes on to say that the changes in training might cause doctors to
be more humble, although that could leave them “a little more hesitant
and uncertain than you might like.” 

In other words, medical educators can change the curriculum so that
doctors in training are more likely to become confident, or to be less
confident.  There are risks either way.  He seems to be
undecided as to which approach is best. 

It is likely that there is no single correct answer.  Some doctors
would be well served to have training that teaches them to be less sure
of themselves.  Others might benefit from a boost in
confidence.  I doubt that it is possible to devise a system of
medical education that always provides each trainee with the optimum
balance between humility and arrogance.  (Yes, that is a false
dichotomy, but it serves a purpose.)

What is more important, is for each physician to be aware of this
balance, to perform a fearless self-assessment, and to develop the
skill of calibrating that balance.  Some patients want their
physician to be decisive.  Others are offended — even frightened
— by that.  So it is not merely a question of each doctor having
the correct balance; rather, it is necessary for each physician to be
able to adapt to the patient’s needs, in each particular
situation. 

There have to be limits to the adaptation.  Some situations truly
are urgent, so there is no time for dinking around.  Other
situations are much less urgent than the patient may appreciate, in
which case it may be best to wait longer than the patient may
like. 

To summarize, there are four ways in which we can consider the balance
between decisiveness and uncertainty.  One in the balance that is
promoted in training.  The second is the balance that is inherent
in each physician.  The third is the balance that is optimum for
the care of each individual patient.  The fourth is the balance
that is optimum for each clinical situation.

The training institution has the ability to influence only one of
these.  The physician comes to the training with a particular
temperament, and will (presumably) act to modify that temperament with
an increasing level of wisdom. 

Note, however, that in the metabalance — the balance of balances —
the patient has significant influence.  The patient can tell the
doctor to be more decisive, or less.  The request may not be
heeded, but it should be heard. 

Rather than have educators worry about the calibration of the balance
in their program, they should endeavor to teach their trainees about
the balance, encourage them to think it through, and teach them that
the balance between hesitancy and decisiveness is not an immutable,
unidimensional entity.  Instead, it is a tool that can be shaped
according to the needs of the patient, and the clinical situation at
hand.

Comments

  1. #1 Erin
    March 17, 2009

    Great post. I think you are right, there is no correct answer. It would be interesting to see how the approaches to teaching vary among specializations (say, podiatry vs. trauma surgery)

  2. #2 Ian
    March 17, 2009

    As we used to say about the painfully young Army MD’s that cursed our hospital every year
    “They’re usually wrong, but they’re never in doubt”….

    Before I pointed fingers at “curriculum”, I think I would want to consider the following three cognitive biases I.D.’d by our learned friends in social psych,

    Dunning-Kruger
    Lake Wobegon
    Downing

    Then I might try looking at David Snowden’s “cynefin” framework particularly when a competent, but not yet capable practitioner exists at the (frightening) boundary between “simple” problems (borderline PD self-harm) and “chaotic” events (truly self-destructive behaviour), when they are sure they can ID the pattern, but error might be catastrophic.

    I think any or all of those concepts might provide a better explanation of why an individual learner might either leap to a judgment or avoid making any decision.

The site is currently under maintenance and will be back shortly. New comments have been disabled during this time, please check back soon.