Mental muscle memory is one the most important things to cultivate when you are learning clinical medicine. It is the process of training yourself to respond in certain ways to certain stimuli. Even if you are facing a completely novel situation, mental training will allow you to carry out the essential tasks in the evaluation without wasting mental energy, that way you can devote all your attention to the novel signs, symptoms, and hazards that you are encountering.
Fire and EMS often do this much better than we do in the hospital. It is rare that a medical student or intern is taught “here are the five things you need to do every time you are in a clinical encounter”, or “when placing a femoral line these are the seven steps you need to carry out to do this safely”. Often in medicine, we tell novices to “watch this a few times”, and then “give it a shot”. If the mentor is good, they will talk about all the steps they are taking to carry out the procedure or encounter, and make certain that the novice understands all the steps. The next step is often not taken, and that is then asking the novice to “talk through” the entire procedure by themselves before they move onto another task. This last step is essential to creating muscle memory, and essential to learning, and it is often not done.
It is puzzling that these educational exercises are not an intrinsic part of the educational process for physicians, and I think if we are going to move to a safer medical culture, they will need to be. In many ways, physicians often have an irrational resistance to any attempt to “cookbook” medical care. I think for many physicians that trained in the 70’s and 80’s they may be a lost cause at this point, since these attitudes are pretty ingrained. But we need to make certain we do not allow these attitudes to gain a foothold in younger physicians.
Here are some muscle memory exercises, and I will put a bunch together for a Kindle offering soon;
1. Step by step account of how to move from recognition of respiratory arrest, to placement of a secure airway. This is probably a 20 step evolution and will often take place under high pressure, therefore it is vitally important to embed these steps.
2. Step by step account of resuscitating a patient with severe medical hypotension. What orders? What labs? Fluids? Antibiotics? Cultures? Etc.
3. Step by step evolution of placing a thoracostomy tube, or a central line
I am not going to write out these steps right now, because people will transfer their disagreement to the steps that I write out, while what I want is for people to realize that the broad concept of consistent clinical thinking is the key, not the individual steps.