Practice Makes Perfect

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Joshua U. Klein, MD, is a third-year obstetrics and gynecology resident at Brigham and Women's and Massachusetts General hospitals.

Most people agree that society has an obligation to train young physicians. In the U.S., academic medical centers -- "teaching hospitals" -- are the setting where this duty is discharged. Most physicians working at teaching hospitals are “academic faculty,” meaning, among other things, that they are responsible for teaching medical students and trainees (they also usually carry an academic title, such as "Professor of Medicine," rather than being known merely as Dr. Smith or Dr. Jones). These academic doctors are also the ones performing scientific research, lecturing in medical schools, writing medical textbooks, and being quoted by the local newspaper regarding the latest developments in their respective fields.

Generally, an implicit understanding exists regarding teaching hospitals. The deal works like this: If a patient wants to be cared for by the famous Professor So-and-So (the one who’s written the book on their disease, for instance), he/she should expect that trainees such as medical students, residents, and fellows will be involved in his or her care. Most teaching hospitals do include the fact that trainees may be part of their care team in the formal consent form that patients sign upon admission to the hospital. But these same consent forms also state that patients have the right to decline to have trainees participate in their care, if they so choose.

I still haven’t decided if it is surprising that the vast majority of patients do not object to having medical students and residents help take care of them (and of course learn from them along the way). But to say that patients express reservations only rarely would be an exaggeration.

One might think that trainees themselves would (or perhaps should) feel indignant about patients violating the “agreement” that exists in the teaching hospitals where they work – and to be sure, some do. On more than one occasion, I’ve heard statements such as, "If they don’t want anyone but their attending touching them, they should find another hospital," muttered in frustration.

My own perspective on this issue is a little more nuanced, however. This is probably because, oddly enough, I have blatantly perpetrated this particular infraction myself. When I was an intern, my wife delivered our son, via C-section, at one of the hospitals where I work. Before the surgery, I waited patiently, and anxiously, as a mid-level anesthesia resident carefully slid an impressively long epidural needle into my wife’s back (twice, in fact, until he handed the needle over to the attending anesthesiologist for the third and ultimately successful attempt; apparently it’s two strikes and you’re out when it comes to placing an epidural).

But when it came time to go to the operating room, I couldn’t restrain myself from asking the attending obstetrician to have a senior obstetrics resident assist with the surgery, rather than calling on one of my co-interns, barely a few months into training -- as would be standard protocol. After all, I knew how uncertain I still was with the instruments in my hands, and I had little reason to think that my colleague who was on call that night would be any more confident (or competent, for that matter).

Ultimately, our obstetrician agreed to my request, a senior resident was called, and everything went fine. But the experience certainly gave me some perspective on the sometimes tenuous relationship that exists between our patients and the young doctors (like myself) who, quite literally, practice medicine on them.