Senior Docs putting faith in shadowing M1s

[velo]

I'm wondering if anyone else has experienced this. I'm an M1 and in my opinion I'm nothing more than a person with a depth of knowledge in the basic sciences, a smattering of random clinical skills I've manage to pick up here and there, and the ability to perform a technically proficient H&P. Really I don't feel like I'm that much more a doctor than I was a few months ago. Still anytime I have had an oppertunity to shadow an attending physician over in the hospital I have been shocked at how much they let you do, or rather I should say just sort of thrust on you.

First experience was shadowing a urologist. Shadowed him in clinic first and the first patient we saw was getting a prostate biopsy. He did a rectal exam first and, apparently finding it interesting, turns to the patient and says "oh the med student should really take a look at this do you mind?" I take a second to realize he's talking about me, and then jump in and do it based on little more than observing what I had seen him do and what I could remember from anatomy about the location of the prostate. Next week I follow him into the OR and at the end get to help close, again based on no training other than what I had observed.

The second noteable example of this phenomenon happend just the other day and prompted the writing of this post. I'm shadowing an attending neurosurgeon. The day starts by trying to track him down based on the vague instruction "why don't you show up for my 8am case?." So after wandering around the surgical floor like a lost puppy for 5 minutes and finally finding a nurse that can tell me what room he's in, I wander into the OR and see a patient I had seen with him in clinic the other day prepped on the table. He was getting an intracranial pressure monitor put in to see if overdrainage of his shunt was causing headaches. I say good morning and the surgeon doesn't say anything (he's a great guy, but not the most talkative), so I stand around for a few minutes before he asks me if I want to go scrub in with the resident. He then jokes (i think) "ha, you'll be the first M1 ever to put in an ICP monitor."

While we're scrubbing the resident starts telling me about the procedure and I feel smart because I had already learned everything about the case the other day seeing it in clinic, so I feel like I'm keeping up. Back in the OR we go over to the patient and he starts telling me about how you drill the hole in the skull, "starts out hard then gets easy as you get through the outer table, then its hard again when you reach the inner table and at the end the drill will dive like you're drilling through a piece of wood so you have to go a bit slower so you don't drive the bit into the brain." Interesting, I think, it will be an experience to see you do that. Then he hands me the drill. I was nervous as hell but I did a pretty good job and had a great story to tell when I got back to class.

I guess with all of this stuff you just have to trust that the senior doc knows its a procedure that you can do to a reasonable approximation and that there's not a great risk of you screwing it up too bad...as long as you're supervised. But still, I just think its interesting that suddenly just because I'm in med school I have the oppertunity to do something like that despite the fact that my "training" was all of 2 minutes long right before I picked up the drill. A year ago if I had taken a drill to someone's skull it would have been assult. Now that I'm in med school its perfectly fine to do it, despite the fact that I really don't have much more training than I had a year ago...

Any thoughts?

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[doc05]

I'll assume they were clinic patients, as opposed to private patients?

 

[automaton]

that's an awesome story and all but i wouldn't go around telling classmates about it. they're probably gonna hate you forever. but it's cool you were prepared and willing to do it. most people would chicken out in your position.

 

[velo]

that's an awesome story and all but i wouldn't go around telling classmates about it. they're probably gonna hate you forever. but it's cool you were prepared and willing to do it. most people would chicken out in your position.

ha, no our class doesn't suck like that. Everyone I've told has just said "wow that's awesome!" One of my friends was a little jealous because she wants to go into neurosurg...but she's shadowing him herself soon, so maybe she'll get to do something cooler

 

[MoosePilot]

You took a drill to a dude's head with no prior preparation? One slip, no specific training, and that makes sense?

 

[velo]

You took a drill to a dude's head with no prior preparation? One slip, no specific training, and that makes sense?

in a word, yes.

Its a relatively low-risk procedure, usually not even done in the OR. It goes through right frontal lobe so its not like you're hitting anything the patient is going to miss. And besides the attending did the actual insertion of the probe. Based on their extensive clinical experience yes it made sense to let me drill the hole under close supervision. The only downside was that it took me faaar longer to drill it than it would have taken them because I was trying to err well on the side of caution, and I think understandably so. Its not like he brought me in and said, "hey, rookie, wanna take a crack at resecting this tumor or clipping this aneursym?" they gave me a job that I would be thrilled to do and that they felt I could do safely under their supervision.

 

[ddmo]

Frightening.

 

[ndi_amaka]

Wow...I remember how I almost panicked when I had to take someone's blood pressure pre-op...and you're talking about a drill to the head. I would have crapped my pants.

 

[MoosePilot]

in a word, yes.

Its a relatively low-risk procedure, usually not even done in the OR. It goes through right frontal lobe so its not like you're hitting anything the patient is going to miss. And besides the attending did the actual insertion of the probe. Based on their extensive clinical experience yes it made sense to let me drill the hole under close supervision. The only downside was that it took me faaar longer to drill it than it would have taken them because I was trying to err well on the side of caution, and I think understandably so. Its not like he brought me in and said, "hey, rookie, wanna take a crack at resecting this tumor or clipping this aneursym?" they gave me a job that I would be thrilled to do and that they felt I could do safely under their supervision.

Well... I only know instructing/supervising student pilots. If something is close enough, there's no way to intervene in time. If you applied too much pressure as you were breaking through the last bit of skull, you'd go into the brain, right? And I'm not a medical student, but would it really be as much a "non-event" as you're describing? Did they take the drill when you got halfway or 3/4, or did you do the entire drilling portion? It sounds like slightly heavy pressure in the last bit of the drilling would equal brain damage.

 

[Dire Straits]

Then he hands me the drill. I was nervous as hell but I did a pretty good job and had a great story to tell when I got back to class.

work

 

[jake2]

Well... I only know instructing/supervising student pilots. If something is close enough, there's no way to intervene in time. If you applied too much pressure as you were breaking through the last bit of skull, you'd go into the brain, right? And I'm not a medical student, but would it really be as much a "non-event" as you're describing? Did they take the drill when you got halfway or 3/4, or did you do the entire drilling portion? It sounds like slightly heavy pressure in the last bit of the drilling would equal brain damage.

Most drills used in neurosurgical procedures have an "auto-stop" mechanism that stops the drill automatically when there is no pressure against it. Thus it stops when you've gotten through the inner table and hit dura/CSF. If you get to scrub in on some neurosurgical cases during your 3rd year surgical rotation, it is not completely unusual to be allowed to drill burholes during sub/epi-dural drainages. It is especially safe there as even if you decide it's a good idea to keep pushing after the drill has stopped, you'll hit a puddle of blood before you touch the brain.

However, even though it is not as essential as other parts of the cortex, I would still perfer not have a drill through my right frontal lobe given the option.

 

[MoosePilot]

Most drills used in neurosurgical procedures have an "auto-stop" mechanism that stops the drill automatically when there is no pressure against it. Thus it stops when you've gotten through the inner table and hit dura/CSF. If you get to scrub in on some neurosurgical cases during your 3rd year surgical rotation, it is not completely unusual to be allowed to drill burholes during sub/epi-dural drainages. It is especially safe there as even if you decide it's a good idea to keep pushing after the drill has stopped, you'll hit a puddle of blood before you touch the brain.

However, even though it is not as essential as other parts of the cortex, I would still perfer not have a drill through my right frontal lobe given the option.

Ah, equipment features that make it less scary. That's cool.

 

[Harrie]

You took a drill to a dude's head with no prior preparation? One slip, no specific training, and that makes sense?

There has to be a first time for everything. Whether you're an MS1, an MS4, or a resident it won't matter for something like this...your first time is your first time. Its not like we get an intern year course called "how to drill holes in someone's skull: an introductory course". There is no preparation.

It seems weird now, but this stuff will happen all the time in 3rd year. See one, do one, teach one sometimes gets flipped around. I know that I did a paracentesis without ever seeing one and I know a few who did their first LP without even observing one.

 

[liverotcod]

Its not like we get an intern year course called "how to drill holes in someone's skull: an introductory course". There is no preparation.

and velocypedalist, you're welcome to drill holes in my skull any time. Maybe some of the voices in my head will ooze out.

 

[electra]

Most senior attendings have a good idea of what you can do and be ready for. I did a bedside thoracentesis and paracentesis (two separate patients). The attending walked me through the entire procedure and everything went great. I feel confident enough now to do this procedure on my own.

If you don't take advantage of these opportunities (especially when the patient is asleep) you really will be missing out. But, obviously, you don't do things you're not comfortable with when the attending is out of the room.

 

[velo]

Most senior attendings have a good idea of what you can do and be ready for. I did a bedside thoracentesis and paracentesis (two separate patients). The attending walked me through the entire procedure and everything went great. I feel confident enough now to do this procedure on my own.

If you don't take advantage of these opportunities (especially when the patient is asleep) you really will be missing out. But, obviously, you don't do things you're not comfortable with when the attending is out of the room.

Exactly, just have to trust that the attending knows enough to know that he can allow you to do the procedure and do it safely if you are supervised. The buck stops with him anyway, if you screw up he's the one whose ass will be on the line...

 

[velo]

bump, I want more krazee 1st year stories...

 

[Scrub MD]

bump, I want more krazee 1st year stories...

Yes! More! More!

 

[saiyagirl]

did the patient know that you would be performing the procedure?

 

[kryptokal]

And I thought I was cool for performing a rectal exam within the first 5 minutes of showing up to my first year clinical mentor's office two weeks into med school.