Tuesday, August 17, 2010

Nay Fellow Way?

It was to be a routine pacemaker.

The parties assembled. The room prepped. IV started. Chest scrubbed. Antibiotics given. His nervous eyes raised when he saw me before the procedure, relieved at the sight of at least one familiar face.

"Are you ready?" I asked.

"Yes," he replied, "I think so."

"Any last minute questions?"

"I don't think so," he said.

"Great! Then let's get this over with..." I turned to the lab staff and signaled them to proceed.

"Oh, doc! I forgot. Can I speak with you a second? Ya know, privately?"

"Sure," I said returning gurney-side. I drew the curtain.

He leaned forward and whispered: "Doc, no fellow, right?"

I stopped and contemplated the question, then acquiesced. "Would you mind if I use one as my scrub tech, but I'll be the primary operator?" I asked.

"Yeah, that would be okay - as long as you're the primary operator."

* * *

This little exchange got me thinking: what would I want? Honestly, I'd probably want an attending physician working on me, too. After all, it makes sense, right? Get the most experienced hands and all.

But there are good reasons to have a fellow involved with your surgery, if the opportunity presents itself:
  • We need to keep training. None of us will be doctors forever, and now more than ever with tons of people entering the health care marketplace there is a need to have well-trained doctors in place to meet the need ahead. You can read all you want about how to do a procedure, but until you've done one yourself on a living, breathing individual, you have no concept of the complexities involved. Starting slow in a closely supervised, supportive setting, makes for some very technically-savvy doctors of tomorrow.

  • They improve your surgical technique. The better I can teach someone to do what I do, it seems the easier it is for me to do it, too. Throughout our careers as doctors, we work hard to solidify our competency "brand" amongst our patients and peers. Particularly for specialists: screw up a case or two and your "brand" is quickly tarnished. This is especially important as we train fellows - none of us wants to tarnish our "brand" when trainees work with us either. Therefore, you better bet that bottom dollar we'll be supervising those fellows closely.

  • Fellows keep you sharp. Oh sure, they often ask mundane questions but occasionally they ask remarkably astute questions, too. When this happens, they make us think and as a result, we all get smarter.

  • They're another set of eyes and hands.It never hurts to have another set of eyes contribute their interpretation to a tough case nor an extra set of hands for that extra retractor. Ever.

  • They slow you down. There is no question that teaching someone else takes more time than doing a procedure yourself. This definitely has its downside. But time spent now might pay large dividends in the future when that same doctor has to work on you someday. Also, spending a bit more time can have it's upsides - especially if you really don't want to have dinner with your mother-in-law.

  • More often than not, fellows are extra-careful. By their very inexperience and their desire to excel in training, I have found most fellows I work with especially conscientious when they dealing with patient and their procedures.
So the next time you have surgery and are introduced to a training fellow in medicine, consider letting a fellow help out on your procedure.

It might just be the best thing you ever did.



Margaret Polaneczky, MD (aka TBTAM) said...

It has often been said that the sharpest docs are fellows just out of training.

They can only get that way if we let them work with us.

I find reminding patients that fellows are already done residency and are just in for additional training helps a lot in getting them comfortable.

Thanks for another great post


Anonymous said...

Good points. Still, the system you describe here in somewhat rarified and benevolent terms has worked, historically, on a considerably less appealing principle much closer to bait and switch. Surgeon A represented the procedure to the patient; Trainee Y performed it. Genuinely informed consent is considerably more complicated for both sides. Ideally, patients take responsibility for educating themselves, and the system articulates intelligent arguments like this one, and docs get educated, without the element of con. Right? or maybe too rarified on my part.

SteveC said...

My Congenital Heart Defect (Tricuspid Atresia) is pretty complex, and my Cardiologist always asks if he can bring a Fellow or student to participate in my examination. I always say yes. Listening to me may enable that young doctor to help someone else in the future.

Adventures of a Funky Heart!

Pluripotent said...

Either physicians in training learn with the guidance of more experienced physicians, as Dr. Polaneczky says, or, if we deny them this opportunity, they learn it on their own, on the fly, without the benefit of a more experienced physician present, once they become attendings themselves. Take your pick.

Anonymous said...

Sorry Doc. I have a "no rookie" rule, with good reason. Practice on somebody else, I've already sacrificed for the cause.

jimbino said...

Interesting. I've taught English, Math and Physics and in all case have felt that I first truly learned the subject in teaching it.

Anonymous said...

When I went into the hospital to have my son, with husband an OB/GYN too, I had no issue with residents and fellow poking and prodding, asking questions, and all that - after three days and the decision made to section, it was when I had to sign the release that I refused to have residents or fellows assist - I wanted only the attending from open to close.

I was, quite frankly, persuaded every which way to allow others to assist...and I still refused. I didn't quite know why --- until five minutes in, my epi FAILED....the residents and fellows ALL FREAKED OUT - but the attending, whom was the only one I consented to for my surgery, kept plugging away as I had no choice at that moment but to continue with surgery WITHOUT ANESTHESIA - oh, the anesthesiologist tried to "snow me" to no end - apparently my adrenyline was counter-acting every last line to attack to get me under.

Needless to say, sometimes patients have a gut feeling - I KNEW something was going to go wrong....and it did....and I thank God everyday I held my ground and said attending only - I'm good, my son was delivered healthy, and those in attendance, observing, learned from a pro how to manage in the face of a very scary situation without freaking out!

And yes, I'm dead serious - it happened to me!

Anonymous said...

Look yes, touch, no. The success of cardiac ablation is proportional to experience. Why on earth would I want someone fresh out of school doing that?

Chris A said...

I know of a child who had a very complex congenital heart defect. When their child was born the family had sought out the best facility and surgeon for her particular defect. She had several heart surgeries and needed another when she was 9. The surgeon who had operated on her from the time she was a baby was to preform this surgery also. He scheduled this little girls surgery for all day. After 7 hours the surgery had gone well. A Fellow was given the responsibility to 'close' this precious child's chest. I beleive what happened was the Fellow sewed into her aorta and she died on the table. The family was told their wonderful little girl who had just died was "part of the learning curve."

We also have a daughter with a heart defect. We always write in the permission for surgery that the, and insert the name of the name of the surgeon or cardiologist, perform the entire surgery/procedure.

Chris A

Stop smoking help said...

Again, we're talking about those functioning in a fellowship. They are no longer "just out of school". All have completed residencies, been drilled by critical care physicians, chiefs of surgery and cardiology, presented 1000s of patients during rounds, given numerous seminars, served as mentors for younger residents/interns, etc.

They are not knew to the neighborhood. They are simply 1-2 years away from being "that doc" which patients want working on them exclusively.

So if they never participate, then who on earth would want to be their first patient in private practice?

Also, after watching tons of procedures where the primary doc had an intern/resident/fellow with them, Dr. Wes is right - the primary becomes very step-by-step in their approach and explains as they go. When nobody else is there, the primary just kind of goes through the procedure and may not be as, what's the word, "instinctual" maybe, in the procedural steps.

Give me another set of curious eyes and a mouth that's not shy about speaking up.

Pluripotent said...

Q: How do doctors become experienced when no one wants doctors in training anywhere near them?

A: Magic.

2ndheartmom said...

As a parent of a heart transplant recipient, I will say that the fellows were some of the most attentive and responsive docs we dealt with. And as a college professor, I always thought that the attendings would not be letting fellows do surgeries they were not ready for - they do work with them on a daily basis after all. I am not sure whether a fellow doing a surgery for their first time would be any different than a full-fledged doc doing the surgery for the first time - and if they don't do it as a first as a fellow, they will do it as a first as a full-fledged surgeon - at least they have the attending backing them up when they are fellows.

We obviously did not have a fellow doing the transplant, but there have been fellows in her cath procedures and assisting with anesthesia, etc. - I've never asked if they just watch and don't touch...I leave that up to the supervising docs and anesthesiologists to decide. Maybe I'm too hands off - but I'm not expert and they are.

Great post!

Lisa said...

Or it could really suck. I had a fellow look at my QTc of 540 and my inverted T waves and tell me that I didn't have LQTS and that beta blockers weren't the proper treatment for it. Then he went on to give me Ondansetron for my nausea because I told him that Zofran and Kytrel were on the list of medicines that I couldn't take. The doctor and the hospital apologised after my EP chewed them out for not consulting him. There are reasons some of us don't want to be treated by fellows.

Anonymous said...

Very Interesting!
Thank You!

Anonymous said...

As I first year medical student, I was diagnosed with thyroid cancer. I was too early in my training to understand how it might work, so when I was referred for thyroidectomy, I assumed that the surgeon that I met was doing the surgery (the head of ENT). I realized at the post-op visit that he had not been at the closing (my external closing was steri-strips only and he was angry). Later, I learned that the chief resident had done my surgery.

At the time of my radio-ablation, the nuclear medicine doctor told me that I had the best thyroidectomy he had ever seen with barely any remaining thyroid tissue in the bed. He was the one that told me the chief resident had done my surgery and that I was quite lucky -- this chief resident had been elevated to chief a year early because someone had left the program, and he was the best operator anyone had seen.

BTW, the resident had used steri-strips to close because he felt like it would be less marring and my skin was coming together so well. You can barely see my scar.

Would I let a fellow or resident operate on me again? Yes, if I had confidence in the training program.

Anonymous said...

I'm glad I train in a charity system. The patients get residents/fellows regardless of preference, or else they can fork out the money to go to the private hospital. It's scary to imagine how unprepared I'd be if I'd trained at a place where patients were able to opt out of fellow participation.