Lessons Learned

After four years as a resident, working an average of 80 hours per week (much more if you’re on labour ward), you tend to think you have seen it all. I have done more vaginal deliveries, cesarean sections, and vacuum-assisted vaginal deliveries than I can count; managed more non-reassuring fetal heart rate tracings, shoulder dystocias, diabetics, and hypertensives than I can remember. It becomes second nature. It becomes your sixth sense. You develop your intuition and you learn to trust it. You develop your skills in using all of your available tools and you trust them. But throughout that you have the reassurance of back-up. If your intuition, skills and tools do not give you the answer, you call your attending. Even when you are completely sure of your decisions, you still call them. But when you begin to practice independently, you don’t have anyone else to call. You have to make immediate, life-altering decisions.

What if you don’t have your usual tools? Then on what do you base your decisions? Intuition can fail you. If you’re interested in this concept, read the book Blink: The Power of Thinking Without Thinking by Malcolm Gladwell. It is eye-opening and riveting. We are constantly taught to second-guess ourselves. We are told “don’t judge a book by its cover” and “think before you act” etc etc… When you begin to think and overthink your intuition, you think of many ways in which to break down your initial judgment. Every argument has a counter argument and you begin finding every piece of evidence that shows you why your intuition is wrong. But there is a reason something is made clear to you by your intuition.

You must learn to trust yourself. I often get compliments about my confidence and I think of it as one of my stronger personality traits. Of course, like everything else in the world there are pros and cons to confidence. I can come off as over-confident, smug, superior, etc. But when confidence is honed by learning, hard work, practice, experience, and hardship, it can be your most important skill. It helps others believe in you, allowing you to be a good leader. It allows you to remain calm and elicit calm from others in difficult situations.

Here, the registrars (residents) do not have back-up. On labour ward they are lucky if they have a consultant (attending) who comes in once or twice a day to round on the patients and make plans. Then they are left to carry out those plans, whether or not they have been taught what to do or how to do it. I am constantly reminding them to call their consultants for help- for their own safety and for the patients. In turn, they constantly remind me that any time they call for help the response is “Why are you calling me? Can’t you deal with it yourself?” (If not worse.) They are often put in situations where they do not have the tools and have not been taught the skills that will give them the right answer. The hierarchical system is such that if there is a bad outcome they will be berated and reprimanded for what they have failed to do correctly before they have ever even learned what the correct thing is. When this is the only system you know, it is difficult to find your own intuition. It is difficult to become confident in your skills and in yourself.

This is an interesting point of distinction from the modern American system of education and medicine. I have asked people here where it comes from and they have told me from the UK system, the system in which everyone here is trained. In the US we have worked so hard over the past 10 or 20 years to dissolve that system, though I don’t know about the modern UK system. As medical students and residents now (or recently) we see the last vestiges of it in certain “old-school” attendings, but for the most part it has been systematically broken down by consciously and actively changing the way in which we interact with each other and our patients. We take classes in ethics and discuss how rigid hierarchical systems in medicine hurt everyone involved, including our patients and ourselves. We are taught that there is a better way to do it and we strive to embody that in our practice. 

These are some of my abstract thoughts at the end of a long day in response to a very difficult clinical situation. The details are not important and I am still struggling to understand and believe them myself. Suffice it to say, I am reminded to always trust my intuition, because my tools and skills may fail me.  When the line between right and wrong is so blurred and when the situation can be so unclear, as it often seems to be here, your intuition and confidence in your ability to be a leader, as well as a team member, are all that will carry you through.  Every day I am trying to teach these skills to the registrars and although the outcome today was bad, I believe the lessons they (and I) have learned from this will make them (and me) better physicians.

The first two pictures are the courtyard in the hospital- it is always filled with people enjoying the sun and fresh air. It is my favorite place to see interesting faces and beautiful children who love to shout "hello!" to catch your attention then grin & giggle & dash away.  The last picture is the beautiful Hindu Temple that I walk past on the way to the hospital every day.