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All posts for the month September, 2012

In many academic medicine situations (and others in Fire and EMS) the immediate supervisor, or slightly more senior provider is often the one teaching the novice something. This is often a matter of expediency since in the middle of the night, the attending, Chief, etc is not there to teach. But I worry that in many disciplines, learners never see a real expert do something. An example is in some mid-level operating room procedures. In many of these the senior resident is taking the junior resident through the case with the attending watching. In those cases, it is likely that the junior resident’s only experience with the procedure is having watched another junior resident taken through the case by another senior resident.

Thus, that junior resident, and possibly the senior resident, have never watched someone who has done 100 of these cases perform the case. There are a lot of things that can be learned by watching an expert do something. I remember my experience from a rotation at a private hospital during my residency. At this hospital, the residents were often first assistants to the attending surgeons. It was the first time I first assisted in my residence on major operations (since usually the attending first assists the senior resident in major cases in academics).  It was very eye opening. Expert surgeons have a different way of proceeding through a case, it appears more like a task than an adventure. They go from task A to task B to task C with little wasted motion. They know the next step and they anticipate it, sometimes moving my hands so I could begin to expose for the next step, since they didnt need the exposure for the step they were on. Anticipation and pre-planning were evident and really moved the cases along. Also since they knew the anatomy, and how to separate structures, there was less bleeding. If theres less bleeding you can see better, and the case moves quicker.

I have told my senior residents that you don’t operate fast by operating fast. You operate fast by knowing what comes next and making sure you’re prepared for the next step, and by taking your time during the critical steps to make sure you get it right the first time. There is a great phrase “there is never enough time to do it right, but always enough time to do it over” that applies. Doing something quickly and wrong takes far more time than doing something slow and correctly.

If you have the opportunity to be with someone with a great deal of experience, watch the way that they do things, not just with their hands, but how they think, how they anticipate, and how they plan the next step. Sometimes great commanders do this in such a way that it is transparent (going to get a stretcher, a piece of equipment, making a radio call for more help before needing it , etc.). Taking the time  to talk to experienced people, understanding why they do things the way they do, and taking their path through a problem can enhance your education in any field.

So now that we’ve talked about the basic premise behind recognition primed decision making, lets go to step 2 – how do you train people when good decisions are based on experience?

If you don’t have experience, then you won’t have a database of cases and scenes in your head to compare to new situations and past plans to choose from to create new plans. If all you need is experience, why spend all the time learning fundamentals, biochemistry, flow dynamics, etc.?

First, in complex situations, you probably could be an adequate practitioner if you just went through 1,000 simulated or real life situations, critically looked at what went on, threw away the bad ideas and kept the good ones, and then moved forward. Unfortunately all your acumen would be based on previous situations and how they came out, you would not have the background to adapt to alterations in new situations, and it would be harder for you to remember what to do under pressure, without some fundamental knowledge of how things work. If you wanted me to be a fire ground commander, or you wanted a master sergeant in the army to be a surgical intern, you could probably accomplish both goals by giving both of us tons of situations, describing the presentations, going through the decisions, and what cues were used to make them, and then go over the action plans, what worked and what didn’t, and putting us both under and apprentice period of close observation. We both would probably not absolutely need the background knowledge, and we would be able to handle most simple situations, but we would have little capability to react to new situations. So our eventual competence would be limited by only what we’d been taught, and what we experienced personally.

So you need some background fundamental knowledge, and real cases, carefully presented and taught. But I believe a training program where you present 90% background scientific fundamentals and 10% demonstration of real life decision making is a lot less effective than 25% background and 75% real life cases, simulation, and apprenticeship.

So when you’re trying to teach new people, or trying to improve the performance of experienced people, it is ESSENTIAL that you focus on those aspects of the call, case, or fire that would have prompted you to move in a different direction than the other person did. Did you see something they didn’t see? Did you put more emphasis on one piece of data? Did they they not recognize the importance of a group of data? If you dont dissect out those issues, then they will not know where their mental model went wrong and they will just make the same mistake again.

Case #1

These are cases presented to me as the student without seeing the cases previously. I am also including the post cast discussion with Joe Sills who wrote the cases. The x-rays you hear me examining are to the right. The CT is for case #1, the CXR is for the trauma patient in case #2. Hope you find it helpful

JY

In the paper I posted by Gary Klein, they show the evidence, and discuss the background to their decision making model known as “recognition primed decision making”. I know many of you are not going to take the time to read the 100 page manuscript (but I highly recommend it, I’m rereading it now and its great), so I’m going to go over some if it. Sorry  I haven’t my podcast on this, but there have been some scheduling issues.

First, Klein says (and I agree) that when an experienced operator, in whatever high-stakes field, encounters a situation (fire, patient, etc.) they do the following:

– Size-up the situation in their mind, assigning it a “schema” based on their previous experience

Explanation: In your mind you record experiences you have had in your profession. With time you categorize those experiences into “boxes” or “schema” of similar situations. In other words, when I see a 80 year old trauma patients on inhalers at home who has 8 right sided rib fractures, I don’t make my clinical decisions based on each of those datapoints individually (elderly+/COPD+/-rib fractures+/- etc.), do it by matching the case to schema I have already created. For this it would be: “old patient with lung problems and big non-lung chest injury”. Then my mind automatically jumps to what I have done for “old patient with lung problems and big non-lung chest injury” in the past and how things have worked out. My plan is based on those past plans and results.

Make a plan based on how patients with this schema have done in the past

Thus my reaction is: “ICU, pulmonary toilet, check if on steroids, try to find previous assessment of lung function (and get ABG to assess current), pain control (with epidural), get out of bed, incentive spirometry, check for wheezing, give inhalers, DVT prophylaxis, watch out for increasing oxygen requirements, check chest x-ray”. That may sound like a lot, but its pretty automatic and doesnt require much thinking, because I’ve taken care of so many of these patients. Why do I have “watch out for increasing oxygen requirements”? Because in my past, we didnt do that and its worked out badly. “Give inhalers” – same thing, at one point we probably forgot to do that and the patient got intubated. Etc.

Keep an eye out for data that conflicts with schema, or which indicate plan isn’t working

This is the sign of an experienced provider, inexperienced people are so happy they came up with a plan that they tend to fixate on it, and don’t accept new data that says their plan is wrong. That’s why new officers and residents need to be watched like hawks. They will tend to push a plan through, even though new data is indicating the plan is not working. It’s not just experience, but ego. Experienced leaders know that things go wrong, and you have to adapt. Inexperienced leaders think changing the plan is an insult to their ego (which is fragile as a new leader anyway) and try to  make reality adjust to the plan, not adjust the plan to reflect reality.

This is just an intro to these concepts. Think about them and we’ll discuss examples from Klein and real life in the next post.

JY