Academic OB/GYN

Last night I had the pleasure to watch an HBO special documenting a masterclass given by singer Josh Groban to three young music students.  Over the course the show, Groban coached the students through composition of an original song, and it culminated with their performance of a song that had not existed a week previously at his concert in Chicago.  It was a great show that I quite enjoyed, and if you like Groban or music, you should check it out.

The show also made me think quite a bit about how my job teaching residents is quite a bit different than the job most teachers have.

During one section of the show, the students played the beginnings of the song that had written.  Josh was quite impressed with what they had produced, but noted that they had yet to write a hook, or chorus, to the song.  The students implied that perhaps the song did not need one, but Josh shut that down pretty quickly.  “Every song needs a hook”, he said, “otherwise its not really a song”.  “In the end, people won’t enjoy it.”  The students absorbed his teaching and agreed the song needed a hook, and that perhaps they had justified not having one because they were having so much trouble coming up with one.

Josh then sat down at the piano with one of the young composers and played through the first verse of the song.   As the verse finished, he put in a nice piano flourish and then played a beautiful chord that so clearly needed to be the first chord of the hook….. and then he stopped, and wistfully got up from the piano.

It was so apparent that Josh could have just kept playing, as it seemed that he had an entire hook in his mind as he played that first chord.   But in the end, it was not his job to write the song.  It was his job to help the young composers.  His duty was to them, not to the song.

I only wish teaching surgery was so easy.

There are many times in surgery where I watch residents struggle with what they are doing.  Sometimes there is something I can say that will help them to succeed, but often what they really need to be allowed to struggle a bit, just as senior surgeons allowed me to struggle when I was in their position.

When a resident struggles, the question I try to ask myself is whether they are struggling because they don’t understand what to do, or if they are struggling because they do not yet have the manual dexterity to accomplish the task with efficiency and fluidity.  If the problem is the former, the answer is that I must try to convey the ideas required to better understand the surgical task, and then help them to accomplish it.  But if it is the latter, I am in a bind.

I am in a bind because allowing the residents to continue to struggle is the best way for them to learn the dexterity they will need to do better in the future, but it is often not the best thing for the patient.   Unlike Josh Groban, when I teach I don’t have a relationship solely with the learners, but also with the patient we are working with.  In the end, the patient has a reasonable expectation that I will use my skills and experience to provide them with the best possible outcome, and will not expose them to excess risk.  But at the same time, surgeons in training cannot progress if they are never given the opportunity to operate.

I often ask myself whether I can serve two different goals optimally at the same time.  That is, can I optimize patient outcomes while also providing the optimal learning environment for the resident physician?  Unfortunately, I think the answer is that I cannot.  There are certain kinds of things that can be learned when one is being led by the nose through surgery, but to learn some things one has be allowed to fail – and in today’s world that is just not acceptable.   We are simply not accepting of increasing the likelihood of a patient coming to harm for the benefit of a learner.

In the past this was not so.  One only has to watch some of the early episodes of ER to see the way it used to be.  Watch the first season you will see multiple occurrences of residents physicians or even medical students learning by making mistakes with live patients, in some cases causing significant harm.   This is not just television – it is the way it used to be.  In my training there were plenty of surgical attendings who were willing to do apparently dangerous things to give their residents experience.  One trauma surgeon routinely gave his senior residents thirty minutes to remove a spleen without any help, and if he or she didn’t have it out he would scrub in, rip the spleen out with his hands, and scrub back out.  Outwardly it seemed like a very dangerous thing to do, and clearly exposed the patient to some kind of risk with no benefit to them.  But in the end, the surgeon was so confident that he could rescue the patient that he did this for the benefit of the residents.  Over time, the residents learned two things: 1) how to stop bleeding from an avulsed spleen and 2) how to take out a spleen in less than thirty minutes.  Putting them under this pressure made them better… but at the expense of potential risk to the patient.    I think the attending would have said he never would have put the resident under that kind of pressure if he didn’t know he or she would be able to rise to the occasion, even if they didn’t know it themselves.  That sounds good, to a point.  But times have changed.  Our culture no longer thinks this is a reasonable thing to do.  I understand it, and in truth I agree with it.   But at the same time I admit that our residents don’t get as well trained as they used to.

I do everything I can to give my patients the best outcomes I can, even if that means less experience for the residents.  That said, I worry that saving patients from harm in our teaching hospitals by holding residents on a tight leash only leads to patient harm in the future, at the hands of our inadequately trained graduates who are finally allowed to make the mistakes they never were allowed to in training – but this time with much less help around to bail them out.

In the end, I don’t think this is going to change.  Maybe it shouldn’t. But I don’t know how to give our residents the kind of training I was fortunate to have, and that is upsetting as well.

And so I envy Josh Groban.   In his masterclass, his only concern was to his students.  The song was irrelevant, a means to an end.   But the teaching physician has it different.  He or she has teach the students, but also has to make sure everything they do is correct.  The teaching physician cannot let them write a bad song, even it is the only way they will ever learn to write a great one.