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Let me start off by saying that this is not a thread about getting into medical school or medical school admissions. It is an every increasing source of frustration on my part that the focus of those interested in medicine is dedicated to getting into medical school, rather than on developing into an individual that medical schools should simply want. This is of course a complex issue, on which I have complex and mixed emotions, but again, is not my intended focus of this thread. It is multi-faceted and certainly not a one sided issue. But I digress...
The inspiration for this comes from Harry Potter. And no, I am not kidding. Not the children's books written by J.K. Rowling, which I thoroughly enjoyed growing up, but what I consider to be REAL Harry Potter book, known as Harry Potter And the Methods of Rationality (found at www.hpmor.com) by Eliezer Yudkowsky. I think that I have read the entire 8 book J.K. Rowling series 5 times. I have now read the entire HPMOR book now for the 8th time, twice taking notes. If I had the power to force my incoming interns this July to read one thing before starting residency, it would be this. Yes, it is a fan fiction. Yes, it can be silly at times. But, it is chock full of very accessible lessons in how to become a better person and how to become a better physician. It is probably NOT accessible to those who have not read Harry Potter because a lot of the charm comes from the off-take from J.K. Rowling's work. For those unfortunate souls that couldn't get into Harry Potter, or are simply too grown up for it, here is the 'boring' version: Sequences - Lesswrongwiki by the same author titled, "Rationality: From AI to Zombies".
My plan here is to take a single topic that I have personally taken to heart from these texts and explain why I think that YOU as someone in medicine or aspiring to train in medicine should care. I tried to come up with a title and started with "guide", "story", etc. To be blunt, these are ramblings. I am not a creative writer. I am well published in the scientific realm for where I am at in my training. But, those looking for excellent prose will not find it. Likewise, these are my examples. They are not global truths. So, with that opening:
[rambling]
The Planning Fallacy
To summarize, I will steal from Wikipedia: The planning fallacy... is a phenomenon in which predictions about how much time will be needed to complete a future task display an optimism bias and underestimate the time needed. This phenomenon occurs regardless of the individual's knowledge that past tasks of a similar nature have taken longer to complete than generally planned. The bias only affects predictions about one's own tasks; when outside observers predict task completion times, they show a pessimistic bias, overestimating the time needed."
I used to think that most people saw the world as glass half empty. But, in my experience, there are very few people that are pessimistic when it comes to planning and it negatively impact physicians personally and professionally. It negatively impacts the physician-patient relationship and I can't prove it, but I think that it leads to worse healthcare efficiency and outcomes.
How long does it take to see a patient when rounding or pre-rounding as a medical student or resident? What about as a staff physician? In my mind, as a surgical resident, when I see my patients at 5am, I am not looking to have a conversation. I am looking for very specific information and I am looking for red flags. I typically see between 10 and 25 patients and need to budget time accordingly. At 5am, most patients are asleep, or mostly asleep. By the time I get to the last patient, it is well past 6am and people are starting to wake up and they want to talk. Like many other residents and students that I know, I fell into the trap of thinking that I could maintain a constant pace. The reality is of course that the interactions are far from consistent and generally do take longer and longer. Most busy people that I know plan based on optimal function and when time starts to crunch they start to cut corners. I have lost track of the number of times where it is clear when running a patient list that attention to detail was maintained through the first half of patients seen, but by the end clearly exams were rushed or even skipped.
It sounds ridiculous that someone would do that. But, it leads to people fibbing on rounds. It leads to delayed care when things need to be rechecked. It leads to exasperation of those more senior to you that you can't, "keep things organized". Which is in my experience, more often than not, not an issue of organization and more an issue of TIME. Something that I learned to do was to simply notice when I was starting to fall behind in any activity that I was doing and address this early. Sometimes it means crying uncle and calling for help, eg. I am stuck dealing with an ER crisis in the middle of morning rounds and I ask another fellow to see a couple of my patients. Sometimes it means cutting a patient off with the promise of continuing the conversation later. However, I watched this become a trap for one of my junior residents this year.
This resident mastered the art of telling patients in the morning that the rest of the team would be by to round on them later in the morning. They would tell them that they would be seen and their questions answered between 10a and 11am, an estimation of when our first case of the morning would be finished and the faculty/fellows/residents would start rounding together on the wards. Invariably, there were many patients that simply weren't seen in that narrow window and led to patients and families being upset that they weren't being cared for or their needs addressed. This resident, like many, including myself, failed to be pessimistic enough about the regularity of a busy inpatient surgery service. We remember a few examples in our head about how the services runs, but fail to register the variability and range of what happens. This resident is far from alone, it is nearly universal that students and residents are overly optimistic about their faculty's schedules.
I have now spent over the past 9 years of medical training a considerable amount of time in both hyper-academic institutions and community facilities. I have taken to heart that medicine is a team sport. While I certainly am open to debate on whether it should be a team sport (or physicians should just run the show, haha, really...), but the reality is that a huge part of a physician's job is interacting with other physicians and ancillary staff. I have seen considerable frustration and bad blood develop from inadequate pessimism about how long physician actions take. I consider it to be a universal truth in healthcare that everyone plans because everyone thinks that they are very busy. Even if you think that nursing, anesthesia, medical residents, etc are playing candy crush and browsing facebook, they are planning out their days and take input from physicians that they interact with, ie. you.
How long does it take to put in a central line? I've heard many residents, mostly the experienced ones try to minimize it to patients or staff saying, "oh, it will take me 10 minutes to put in." Nothing takes 10 minutes. Even when everything goes perfectly and you couch your "10 minutes" with a, "Well it will also take me 10 minutes to get the room setup." Invariably it takes longer. From consenting the patient to gathering supplies to herding family out of the room to prepping to actually doing the procedure to waiting for XRAY to come, not only do things take longer than expected, there are 10 different points where something can happen that slows you down. Most experienced residents will have factored in the anatomical challenges (small vein, large panus, patient being contracted, etc.) or other "medical" issues like needing to wait for platelets to arrive, but don't routinely factor in the social issues or the unexpected. Those delays become delays for everyone waiting on that line and often everyone waiting for you and your services (in the ER, clinic, to round, etc). This is clearly an example from my world, but I have noticed lord knows how many other examples that have affected interpersonal relationships within the hospital.
I'll keep this one brief because I don't think that people will have a hard time appreciating. As a physician, no matter what you go into, you are going to be busy at points in your training. I have seen spouses, significant others and friendships frayed as a result of the planning fallacy and no, it is not all in surgery. It is always better to lower expectations and come home earlier than expected than the reverse, even if you are coming home at the same time. It will also lower the pressure on you to race out of the hospital, which is dangerous in and of itself.
Lastly, reliability. If there is one thing that I value more than anything else in a physician, it is reliability and I have noticed that patients and my bosses, whether they admit it or not seem to as well. From a research perspective... The number one reason that residents and medical students miss their deadlines, both self-imposed and mandated is the planning fallacy. I have worked with maybe 2 dozen medical students on various research endeavors, I can only think of two that worked faster than they thought that they would. I am historically guilty of this as much as anyone. Probably the most frequent negative response I hear from my staff about medical students working with us is, "where did that student go? I thought he was putting this together last month?" Well, that student (or resident) got busy with 50 million things that trainees get busy with when in clinical training. Do not underestimate the roadblocks in research. Sometimes it is external as alluded to above, things come up. But, often it is internal to the project, sometimes they just simply don't know how to keep the project going or what the next step is and are waiting for someone to guide them forward.
Okay, I think the wall of text is large enough and I can stop.
The inspiration for this comes from Harry Potter. And no, I am not kidding. Not the children's books written by J.K. Rowling, which I thoroughly enjoyed growing up, but what I consider to be REAL Harry Potter book, known as Harry Potter And the Methods of Rationality (found at www.hpmor.com) by Eliezer Yudkowsky. I think that I have read the entire 8 book J.K. Rowling series 5 times. I have now read the entire HPMOR book now for the 8th time, twice taking notes. If I had the power to force my incoming interns this July to read one thing before starting residency, it would be this. Yes, it is a fan fiction. Yes, it can be silly at times. But, it is chock full of very accessible lessons in how to become a better person and how to become a better physician. It is probably NOT accessible to those who have not read Harry Potter because a lot of the charm comes from the off-take from J.K. Rowling's work. For those unfortunate souls that couldn't get into Harry Potter, or are simply too grown up for it, here is the 'boring' version: Sequences - Lesswrongwiki by the same author titled, "Rationality: From AI to Zombies".
My plan here is to take a single topic that I have personally taken to heart from these texts and explain why I think that YOU as someone in medicine or aspiring to train in medicine should care. I tried to come up with a title and started with "guide", "story", etc. To be blunt, these are ramblings. I am not a creative writer. I am well published in the scientific realm for where I am at in my training. But, those looking for excellent prose will not find it. Likewise, these are my examples. They are not global truths. So, with that opening:
[rambling]
The Planning Fallacy
To summarize, I will steal from Wikipedia: The planning fallacy... is a phenomenon in which predictions about how much time will be needed to complete a future task display an optimism bias and underestimate the time needed. This phenomenon occurs regardless of the individual's knowledge that past tasks of a similar nature have taken longer to complete than generally planned. The bias only affects predictions about one's own tasks; when outside observers predict task completion times, they show a pessimistic bias, overestimating the time needed."
I used to think that most people saw the world as glass half empty. But, in my experience, there are very few people that are pessimistic when it comes to planning and it negatively impact physicians personally and professionally. It negatively impacts the physician-patient relationship and I can't prove it, but I think that it leads to worse healthcare efficiency and outcomes.
How long does it take to see a patient when rounding or pre-rounding as a medical student or resident? What about as a staff physician? In my mind, as a surgical resident, when I see my patients at 5am, I am not looking to have a conversation. I am looking for very specific information and I am looking for red flags. I typically see between 10 and 25 patients and need to budget time accordingly. At 5am, most patients are asleep, or mostly asleep. By the time I get to the last patient, it is well past 6am and people are starting to wake up and they want to talk. Like many other residents and students that I know, I fell into the trap of thinking that I could maintain a constant pace. The reality is of course that the interactions are far from consistent and generally do take longer and longer. Most busy people that I know plan based on optimal function and when time starts to crunch they start to cut corners. I have lost track of the number of times where it is clear when running a patient list that attention to detail was maintained through the first half of patients seen, but by the end clearly exams were rushed or even skipped.
It sounds ridiculous that someone would do that. But, it leads to people fibbing on rounds. It leads to delayed care when things need to be rechecked. It leads to exasperation of those more senior to you that you can't, "keep things organized". Which is in my experience, more often than not, not an issue of organization and more an issue of TIME. Something that I learned to do was to simply notice when I was starting to fall behind in any activity that I was doing and address this early. Sometimes it means crying uncle and calling for help, eg. I am stuck dealing with an ER crisis in the middle of morning rounds and I ask another fellow to see a couple of my patients. Sometimes it means cutting a patient off with the promise of continuing the conversation later. However, I watched this become a trap for one of my junior residents this year.
This resident mastered the art of telling patients in the morning that the rest of the team would be by to round on them later in the morning. They would tell them that they would be seen and their questions answered between 10a and 11am, an estimation of when our first case of the morning would be finished and the faculty/fellows/residents would start rounding together on the wards. Invariably, there were many patients that simply weren't seen in that narrow window and led to patients and families being upset that they weren't being cared for or their needs addressed. This resident, like many, including myself, failed to be pessimistic enough about the regularity of a busy inpatient surgery service. We remember a few examples in our head about how the services runs, but fail to register the variability and range of what happens. This resident is far from alone, it is nearly universal that students and residents are overly optimistic about their faculty's schedules.
I have now spent over the past 9 years of medical training a considerable amount of time in both hyper-academic institutions and community facilities. I have taken to heart that medicine is a team sport. While I certainly am open to debate on whether it should be a team sport (or physicians should just run the show, haha, really...), but the reality is that a huge part of a physician's job is interacting with other physicians and ancillary staff. I have seen considerable frustration and bad blood develop from inadequate pessimism about how long physician actions take. I consider it to be a universal truth in healthcare that everyone plans because everyone thinks that they are very busy. Even if you think that nursing, anesthesia, medical residents, etc are playing candy crush and browsing facebook, they are planning out their days and take input from physicians that they interact with, ie. you.
How long does it take to put in a central line? I've heard many residents, mostly the experienced ones try to minimize it to patients or staff saying, "oh, it will take me 10 minutes to put in." Nothing takes 10 minutes. Even when everything goes perfectly and you couch your "10 minutes" with a, "Well it will also take me 10 minutes to get the room setup." Invariably it takes longer. From consenting the patient to gathering supplies to herding family out of the room to prepping to actually doing the procedure to waiting for XRAY to come, not only do things take longer than expected, there are 10 different points where something can happen that slows you down. Most experienced residents will have factored in the anatomical challenges (small vein, large panus, patient being contracted, etc.) or other "medical" issues like needing to wait for platelets to arrive, but don't routinely factor in the social issues or the unexpected. Those delays become delays for everyone waiting on that line and often everyone waiting for you and your services (in the ER, clinic, to round, etc). This is clearly an example from my world, but I have noticed lord knows how many other examples that have affected interpersonal relationships within the hospital.
I'll keep this one brief because I don't think that people will have a hard time appreciating. As a physician, no matter what you go into, you are going to be busy at points in your training. I have seen spouses, significant others and friendships frayed as a result of the planning fallacy and no, it is not all in surgery. It is always better to lower expectations and come home earlier than expected than the reverse, even if you are coming home at the same time. It will also lower the pressure on you to race out of the hospital, which is dangerous in and of itself.
Lastly, reliability. If there is one thing that I value more than anything else in a physician, it is reliability and I have noticed that patients and my bosses, whether they admit it or not seem to as well. From a research perspective... The number one reason that residents and medical students miss their deadlines, both self-imposed and mandated is the planning fallacy. I have worked with maybe 2 dozen medical students on various research endeavors, I can only think of two that worked faster than they thought that they would. I am historically guilty of this as much as anyone. Probably the most frequent negative response I hear from my staff about medical students working with us is, "where did that student go? I thought he was putting this together last month?" Well, that student (or resident) got busy with 50 million things that trainees get busy with when in clinical training. Do not underestimate the roadblocks in research. Sometimes it is external as alluded to above, things come up. But, often it is internal to the project, sometimes they just simply don't know how to keep the project going or what the next step is and are waiting for someone to guide them forward.
Okay, I think the wall of text is large enough and I can stop.
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