It rolls off your tongue so easily. See-one, do-one, teach-one has been the mantra recited to doctors-in-training for hundreds of years. It purports to characterize the process by which technical skills are passed from one generation of physicians to the next. However, you know as well as I do that the process of learning a skill such as performing a lumbar puncture on a squirming 6-month-old almost never conforms to the see-one, do-one, teach-one dictum.
Although I recall that it was not until my 7th birthday that I could consistently and confidently tie my own shoes, I consider myself reasonably dexterous. As a woodcarver, I was comfortable around sharp instruments, but that comfort zone quickly disappeared when it came to poking and cutting another human being who had nerves and blood vessels.
Even though the procedure may have looked effortless and easy in the hands of my instructors, when it came time for me to begin the do-one part of the process, the sweat began flowing from every pore on my body. I still had enough ego left to deal with the high likelihood of failure. But, how much damage and pain was I going to inflict on the unfortunate patient during my failed attempt or, more likely, multiple attempts? Where did that “at first do no harm” thing fit in here? Shouldn’t there really be a “try some” in middle of that training mantra? And that raises the question of, How many is “some”?
In a Pediatric Perspective in the June 2017 issue of Pediatrics, two anesthesiologists at Texas Children’s Hospital in Houston and the Children’s Hospital of Philadelphia address that question of, How many tries is reasonable for a physician attempting to learn a new technique (“When Should Trainees Call for Help with Invasive Procedures?” Pediatrics. 2017, June. doi: 10.1542/peds.2016-3673 )? They illustrate their insightful discussion with the gruesome image of the wrist of an infant who had endured 21 attempts at percutaneous arterial line placement.
In addition to direct supervision, the authors recommend that instructors engage the trainee in a preprocedure discussion that includes setting a predetermined number of unsuccessful attempts at which the trainee will stop and ask for help. They suggest that the “trainee should be taught the self-insight to summon a more experienced provider or perhaps just a fresh pair of hands.”
For the general pediatrician or family physician, many of the technical skills we learned in training are likely to fade from disuse in the real world of office practice. However, learning when and how to step back in the face of multiple failures is a skill that every physician will continue to use regardless of where he or she is on his or her professional trajectory.
It isn’t always easy. It challenges our egos to ask for help when we have failed at making the diagnosis or not chosen the most effective therapy. At a minimum, stepping back and taking a deep breath (or three) may allow us a window through which we can finally see outside the box we find ourselves in.
Persistence is an attribute that allowed us to navigate the long and challenging path of our medical education. But, there are situations when it gets in the way of good medical care.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.
