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Trial and error: Taking a cheat sheet to work

Taking a cheat sheet to work

It was the first week at my final internship and we were doing ward rounds. As always, I had my little paper with a description of every patient in the ward with me as a quick reminder before seeing the patient. Afterwards, the resident told me that was the most unprofessional thing she had ever seen. Well, no notes for me anymore. The next day I tried to memorize all treatment plans of the patients. I totally messed up. “We will perform an X-ray, oh no, sorry, that was your neighbor.”

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Trial and Error: Understanding an uncommon fracture

Understanding an uncommon fracture

“No, our family is not supported by a social worker.” Jesse’s mother is visibly annoyed now. “Jesse* is a very energetic child, but we are doing fine.” Jesse, a heated, whining toddler of 16 months old, showed up at the emergency department in his pyjamas tonight. His mother explained that his leg got stuck between the bars of his bed. Now it hurts badly, and the emergency physician found a spiral shaft fracture of the tibia on the X-ray. Our conversation becomes increasingly unfriendly, and after fifteen minutes, she loudly screams that she is not a criminal and takes Jesse home. Communication has broken down making it impossible to further investigate the worries of the emergency physician about possible abuse. We feel forced to report the case to the national child protection agency.

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Trial and Error: Honesty is the best policy

Honesty is the best policy

It was my final internship at the department of Cardiology, the final test before becoming a real doctor. My supervisor had asked me to attend to a patient at the Oncology ward. The patient was diagnosed with stage IV lung carcinoma and the oncologist was worried about malignant pericarditis. I did a physical exam and went back to my supervisor.

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Trial and Error: Attitude leads to gratitude

Attitude leads to gratitude

The term „trial and error” might make one think of failed experiments. However in this article I would like to point out that one of the biggest mistakes in research is not blowing up the laboratory but having the wrong attitude.

After becoming a Medical Doctor, a PhD seems an excellent opportunity to increase your knowledge, skills and career opportunities. With this in mind I enrolled in such a program, concerning both the Internal Medicine and the Pathology department. During my first year it became clear that the bulk of the work was going to be laboratory work, very much pathology orientated. For a person who loves the clinical practice and whom has his heart set on becoming an Internal Medicine specialist, this meant I had to adapt. Nonetheless, I presented myself as extremely confident regarding my abilities, supposedly obtained whilst working in the clinic as an intern. I was trained as a doctor ergo, how difficult could laboratory work possibly be…

Funnily enough, this overconfident attitude towards colleagues and my blatant disregard for standard operating procedures, nine to five mentality or cleaning duty in the laboratory, did not prevent my lab-mates from being kind and helpful. However this attitude did have a negative influence on my state of mind and therefore on the quality and progress of my research.

In retrospect, insecurity was the basis of my overconfident attitude, as it often is. The moment I recognized and acknowledged my insecurities, was a moment of personal growth. I became more susceptible to advise and therefore was able to learn a great deal more. Furthermore, I learned not to compare myself to the well-trained laboratory technicians and biomedical scientists. We all have a role to play in the lab. They have experience and skills, while doctors can be a link between the laboratory and clinic. And lastly, I learned that it’s OK to be vulnerable and to show your insecurities.

Halfway  through my 4-years of PhD-training, I am becoming more and more comfortable in the lab. When looking ahead to my return to the clinic, I feel that this “switch-back” will form a test as well. Hopefully I have learned to present myself, even when I feel insecure, and how to set achievable goals in order not to make the same mistakes again. My (t)error  illustrates the challenge of choosing the right attitude for recently graduated doctors whom enroll in laboratory orientated PhD programs. For this much needed attitude adjustment I am grateful.

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Trial and Error: Observe and listen

Observe and listen

During the first day of my psychiatry internship an alarm went off. It was from one of the rooms on the closed psychiatric ward. Apparently, one of the patients was physically and verbally aggressive towards other patients and also to one of the nurses. It was decided to transfer the patient to one of the isolation rooms because he was refused to calm down and go back to his room to take his medication. I joined the group of nurses that were going to guide the patient to the isolation room. I asked if I could be of assistance, but as an intern there are moments where there is nothing one can do and this was one of them. Ultimately they managed to bring him to the isolation room, where he again refused to take his medication. Subsequently, I witnessed how the was given medication against his will; all I could do was not to interfere.

A few days the patient had calmed and was cooperative and was allowed to leave the isolation room. Not long after that, he approached me. He recognized me and told me that he noted that all the doctors where busy, yet he wondered whether I had time to talk. The following days we sat down to talk every time he was feeling upset. During one of our conversations he told me he felt relieved that someone took the time to listen to his frustrations. As an intern you always want to do as much as you can. It may appear that simply observing and listening is not ‘the real thing’. But during this internship I learned that it is a mistake to think this way. Sometimes this is all you can do, but at the same time it is more than enough.

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Trial and Error: Polypharmacy

Polypharmacy

Geriatric medicine has always fascinated me. I wanted to gain more experience with complex cases of the growing population of the elderly with comorbidities and polypharmacy. Therefore, I decided to pursue my last medical internship at the geriatric medicine department. Evaluating my first patient I realized how easy it is for a (soon to be) doctor to think a patient current medication would not need any alternations.  After all, all drugs are all prescribed for a reason. As you would figure, I was too, naïve. When I discussed the first patient with my supervisor I was confronted with the question: “What is the indication to continue this drug?” To be honest, I had no idea. I knew what the indications were of certain drugs, but I did not look into the indications for which this specific drug was prescribed to this patient. It seemed quite straightforward to me: this patient had pregabalin, marketed under the brand name Lyrica, so she was probably suffering from neuropathic pain.

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Trial and Error: Aspiration

Aspiration

The CT-scan of a 75-yrs old male, with recently discovered biliary pancreatitis for which he underwent multiple endoscopic retrograde cholangiopancreaticography (ERCP) showed an increased development of necrosis. Due to this acute setting, indication for video assisted retroperitoneal drainage was determined. Before the procedure, the patient was seen by an anesthesiologist. Because of the emergency setting no pre-operative optimization was feasible. Patient underwent procedural sedation analgesia (PSA), but almost instantly after initiation of sedation regurgitation and aspiration was observed, what made immediate intubation ventilatory support (↓ SpO2) and the placement of a gastric tube necessary. The procedure was continued, during which the patient became hemodynamically instable. The patient was admitted to the ICU afterwards, but four days postoperatively little had changed in ventilation requirements.

The main predisposing factors for aspiration are emergency settings and inadequate anaesthesia.1 This makes one wonder what could have been done differently to avoid aspiration; Postponing the procedure (due to emergency not a real option), placement of a gastric tube pre-procedurally, use of a different patient positioning, or anesthesia with rapid sequence intubation (RSI) instead of PSA? There is no clear evidence for the use of, for instance,  anti-Trendelenburg position during intubation, but it should be avoided in morbidly obese patients2,3. Though, aspiration is reduced in a semi-sitting position4, airway management might be more difficult. The nauseousness caused by the patient’s condition, made him regurgitate. Suctioning via a beforehand placed gastric tube might have reduced gastric volume. However, this would have only worked for clear fluids, more solid contents cannot be suctioned via a gastric tube, thus success of this intervention is debatable. Moreover, the gastric tube had to be removed since otherwise the lower esophageal sphincter remains open increasing the likelihood of regurgitation.  Furthermore, there is no evidence that RSI is able to reduce aspiration and it has several complication of its own.5 Nevertheless, it might have been done, since RSI is recommended for patients at risk of aspiration by all guidelines.

In the future, use of anesthesia with RSI instead of PSA for patients with increased likelihood of regurgitation will most likely be the better choice.

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Trial and Error: The young female intern – Clarify your role

The young female intern – Clarify your role

“Nurse, can you help me sit up?”, “Nurse, I would like to pee.”, “Thank you, nurse”. These are sentences I, as a female doctor in training, heard frequently from patients during my internship at internal medicine. I visited the patients that were addressed to me daily, never correcting patients because the mix up did not really bother me. At the end of one day a nurse came to me and said that a patient had complained that although there was a very friendly nurse, the doctor never visited him. He was almost at the point to make an official complaint about this. I was sure I visited this patient that day, but because I had not corrected the patient in his “thank you, nurse” he never knew I was the doctor (or in this case: the medical student).

As a young female intern it is always possible that a (often elderly) patient addresses you as nurse. In their beliefs, by experience, cultural background or because it has always been that way, a female is a nurse and a male a doctor (of course this is somewhat exaggerated). I never felt annoyed nor offended when a patient called me nurse, but I also did not correct them. Moreover, I never requested a nurse to help explaining that I was not the nurse but a medical student.

Following the experience with the unsatisfied patient about the medical attention he presumably had not gotten, I now always make clear I am a doctor-in-training. This is not just to avoid complaints, but it can be reassuring for patients to know that the doctor is giving them the attention they need.

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Trial and Error: The Tortoise

The Tortoise

To slow! After a quick look at all the feedback forms I gathered during my rounds, I realized that my main reoccurring error was that I was not quick enough. Somehow all my supervisors came to the same conclusion; this young doctor is not able to sprint.

I vividly remember my first feedback form, the pro’s were read and promptly forgotten, but the con’s: oy…they stuck in my mind, making my next round a complete joke. Have you ever seen a tortoise trying to sprint? In my effort to be quick, I lost the joy of learning. I had set aside my holistic ideals in an attempt to improve my weakness. In doing so, I tried to change the nature of my character and guess what: I failed! Not only did I fail, the whole process of trying gave me the feeling that I was not competent, not capable and foremost not good enough to ever succeed in any medical profession. Observing all the hares jumping from one patient to another in an endless winning streak, I lost confidence in myself. However, through trial and error I now know that the goal of negative feedback is not always change. It is the awareness of your speed, your style and your character that is far more important than change itself. Once I realized that, I was not doubtful about my speed anymore, I knew it was part of the way I do best. My advice is to stay true to your character, use feedback to understand your talents and shortcomings, and by doing so become quicker than the hares.

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Trial and Error: Catching a virus

Catching a virus

At the Tytgat Insitute for Liver and Intestinal research, next to the AMC main building, PhD students are passionately trying to make their first scientific mark on their respective fields of study. To study human diseases many of these researchers rely on intricate mouse-models, which can provide important insights on pathophysiological mechanisms or novel treatments. These precious and valuable mice can be very challenging to breed and, as you can imagine, are carefully kept in a clean facility. Despite these precautions, this facility recently was infected with a very virulent mouse hepatitis virus. Understandably, when this was discovered all researchers who were in the middle of their experiments were fearful of having to throw away their data. As we speak, their mice are being tested whether they really are infected or not, a time-consuming process. Furthermore, the whole facility must be cleared out, meaning that most mice must be sacrificed. For many researchers, this means starting over and breeding their mice of interest all over again..

Although very misfortunate, this event offers us an important lesson. In scientific research, a proper back-up of the data on your computer is not sufficient to prevent the setbacks of a virus-infection. It is also crucial to cryopreserve embryos or sperm of your valuable genetically modified mouse strain. Since not only computers can catch a dangerous virus, mice can as well

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