Helen Carnaghan: The messy business of learning

Helen CarnaghanMany things have changed during my transition from medical student to junior doctor. For starters my bank account contains a mysterious thing called money, a 30 minute lunch break is something I dream about and leaving hospital on time a distant memory. Amongst the changes one of the biggest is the way I learn.

From the relative safety of medical school, where the busiest dangers were “teaching” by humiliation, spilling tea on my textbook and falling asleep in lectures, I entered a world in which I have acquired a new level of responsibility.

I have of course underplayed the experience of being a medical student given that any patient encounter holds a risk of causing upset, offense or harm. However, a new layer of accountability has been added, that of clinical decision-making with my actions directly impacting patient health and wellbeing. This risk of doing harm is what underpins my change in learning.

We are taught in medical school that all clinical decisions are a balance between benefit and risk to patient health. This is particularly felt by “newbie” doctors due to our limited first hand experience of side effects and complications.

I was particularly struck when one of my patients developed large volume melaena after starting therapeutic clexane for pulmonary embolism. I had prescribed the drug in discussion with my team and even though the patient had no contraindications for anticoagulation I felt a great sense of responsibility for its side effects. I did though learn important lessons: Firstly, anticoagulation shouldn’t be started lightly. Secondly, although we try to minimise risk it can never be eliminated. Finally, patients may not respond in the way we expect.

On a lighter note, I learnt a valuable lesson in colleague communication by making the unfortunate mistake of explaining to a radiologist I had “ordered” an x-ray for x and y reasons. Only to be quickly interrupted and informed that “radiologists are not a takeaway service and investigations are not ordered but requested”. I thought it unwise to further raise their blood pressure by pointing out the ‘request’ card is ironically titled ‘radiology order form’! My lesson, all specialties have their sore spots. Avoid them at all costs or be prepared for an ear bashing.

The long and the short of it is that now a large proportion of my learning occurs through unexpected outcomes and adverse events. My learning that previously seemed uneventful is now messy and my favourite quote has become; “A person who never made a mistake never tried anything new” (Albert Einstein).

Helen Carnaghan is a Foundation Year 1 doctor in the Eastern Deanery and a member of BMJ Junior Doctor Advisory Panel.

  • Dear Helen,
    your interesting paper is worthy of accurate and large discussion,in my opinion. In fact,I love it because of numerous reasons. For instance, asking Google.com “Single Patient Based Medicine”, you will find that I am the founder! Among a lot of other reasons, the most paramount one is certainly the following distressing consideration. All around the world, every week are published thousands of famous peer-reviewes in Medicine field, which inform seemingly physicians on to often sensationalising, but temporary, Medicine advances; see, for instance, the recent business on synthetic blood, we are told, we shall utilize in three years!!! Well. In spite of these medical progresses in all disciplines, laymen as well as doctors of the world are continueing erroneously to think that ALL individuals may be involved by Diabetes, CAD, Cancer, a.s.o., so that every patient udergoes -in day-to-day praxis, ER, Hospital – to test for glycemia, ECG, Ecogardiogram, oncological markers…..
    Importantly, nobody has until now confuted my article: Middle Ages of today’s Medicine, Overlooking Quantum-Biophysical-Semeiotic Constitutions and Related Inherited Real Risk. http://www.sciphu.com November 4, 2008. http://sciphu.com/2008/11/meadle-ages-of-todays-medicine.html
    I suggest you and BMJ Editors to start a honest discussion on this surprising topic: <>.

  • Dr Afzal Khan

    I appreciate you are so keen and have a deep concern with patients regarding to thier disease.in my opinion intelligent person also learn a lot from their mistakes.

  • Dr. Anoop C. Dhamangaonkar

    Dear helen,
    I’m the junior house surgeon in Orthopaedics in a busy and prestigious general hospital. I can totally identify with the drastic change that you are undergoing. But I feel that the word responsibility is ‘ingested’ but not ‘digested and assimilated’ by the junior clinical resident. The major reason for this is that during this transition from the comfortable confines of student life to the real, wide, extremely hectic professional life, at least for the first few weeks or months, there is slightly more focus on self-care than patient-care and there lies the problem!
    Now, according to me, the principle is simple, the faster the student cares equally for self and patients or even more for patients in time of need, the faster the resident learns. This promotion comes only when ‘responsibility’ is ‘assimilated’ by the junior resident.
    I questioned myself, how can this assimilation be hastened?

    1. the most common cause for delayed assimilation is that each and every action of a junior resident is covered by his/her senior. this obviously cannot be hastened but seminars and case presentations could be arranged and during these seminars, cases must be independently presented by juniors to seniors.
    2. In busy set-ups, the ‘doing’ is done by the junior resident and the ‘decision-making’ is done by the seniors. Hence, the resident learns by observing ‘what’ he is doing. This no doubt adds substantially to the residents’ knowledge. But what would add to this learning if the junior resident learns from ‘why’ he is doing ‘what’ he is doing. This could be facilitated by involving juniors in the case discussion and decision-making.
    3. The other method which i find effective to hasten assimilating responsibility, is to imagine that the patient is one of your near and dear ones or more effective is to identity with the patients who are having a similar illness as you had! since I’m down with fever now and that too being aggressively treated, i fully know my responsibility when a patient complains of fever! I know it’s a bit of a cliché, but it does enhance patient-care.
    4. The last thing that makes one assimilate responsibility is obviously when one becomes a senior!! So junior residents don’t wait till this inevitable eventuality!

    Thanks for sharing your experience!