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.