Yesterday, I wrote:
the most important three words of Third Year are: I DON’T KNOW.
Today we had our end-of-clerkship exercise for Family Medicine. It had very little grade-point value attached (a few pithy percentage points and, qua Woody Allen, 80% of those points were guaranteed by showing up). I load my first simulated patient encounter, and the door note is posted. The sole task is to counsel a mother on childhood immunizations. That’s it. No history, no physical. Just go in and recite, from memory, every standard immunization in order.
I knew from reading the door note that I would “fail” this portion. I walked in, washed my hands (reflex habit, I get nervous when I walk into a patient room and don’t wash my hands), pulled up a chair next to the mom. “So,” she says, “I’m here today because I want to know what vaccines my child will be getting next week during their visit.”
PAUSE: this is totally unrealistic. Who makes a doctor’s appointment solely to talk about their child’s upcoming vaccines? No one would ever be that considerate. RESUME
I’m standing there, facing this “anxious mother” pushing a “baby” in a stroller (the stroller was real), and my heart drops. I know I don’t know the answer. After five seconds of awkwardness, she knows I don’t know the answer. The use of cell phones: forbidden. Time-outs to leave the room and ask your preceptor or look up the answer: forbidden. I know from the door note that there is literally nothing else I am supposed to do in this simulated room.
I thought about what I had written last night, and looked this “mother” straight in the eye and said “I don’t know. [PAUSE] At this point, if you have no other questions, I would look up the answers to your question, or ask my preceptor, and then come back and resume answering your questions. I am happy to name all of the immunizations your son should get by age 6, however, I am not inclined to guess at what exactly your son should be getting at their next visit. Let me write the standard childhood immunizations out for you on your schedule, without dates, and we can talk about any questions you have at that point.”
Did I “fail” the exercise? Probably. I wasn’t able to complete the key task. However, I didn’t lie, didn’t knowingly pass along false information, and didn’t mislead the patient with false confidence in a questionable, shaky reply. I don’t think I deserve a pat on the back … well, at least I didn’t, until I heard what some of my classmates did.
“Oh, I just guessed.”
“I made something up. The mom looked at me funny, but, then I just said that I wasn’t too sure anyways she probably knew better than I did, being a mom and all.”
“Yeah I just bullshitted my way through that one.”
I am really disinclined to get on my high horse here, because it’s never that simple. Many times in medicine, you do have to advance your best guess, because you believe it’s the best information you can give your patient, because you’re in a safe environment or because you know that you’re speaking with someone who knows the answer (such as your attending). However, there is a rubicon out there, and it’s up to each of us to define it and patrol it ruthlessly. For me, facing a patient, simulated or not, locates you in territory that is firmly across that river.
I think what you do when the stakes are low, or when no one is watching, reveals your character. I was tested yesterday to live up to what I had written, and in a way, I passed (obviously, the real test was whether or not I knew the material, and in that instance I did not and I failed).
Furthermore, actions repeated over time become habits, and habits are hard to break. Yes, it was VERY embarassing to admit that I was failing the encounter in front of the actor, (and since it was on video) the simulation center director and the family medicine clerkship director. But I decided in that split second that admitting the embarrassing truth was better than, even in this fake no-stakes encounter, even for a second, deciding that avoiding embarrassment was more important than giving the best information to the patient. If I need to remediate this exercise, then so be it.
I’m proud of my decision and I hope that if I am ever faced with a higher stakes situation, I’ll make the same decision again.
The rest of the simulated exercises went fine, our NBME test today was difficult, but I’m looking forward to a nice day by the lake, a restful weekend and a great start to OB-GYN (yikes!!) next week.