#117 Self-Doubt is Normal
We need it to grow
I will never forget the first time that I used water to flush out the wax built up in the ear of an elderly lady. I was doing a medical school rotation through an Ear, Nose & Throat (ENT) office. The water must have been too cold and right in front of me, the lady started flailing her arms around and yelling that the room was spinning. She nearly fell out of the elevated examination chair. I was shocked and dumbfounded.
I had inadvertently stumbled into a test of her vestibulo-ocular reflex. When water that is too cold or too warm is placed into the external ear canal, the auditory nerve activates the part of the brain stem is that controls balance. The test was once used to test for brain stem death in intensive care patients before more modern forms of brain wave testing.
My patient’s acoustic nerve and brainstem were working quite well, thank you, life, for that quick and dramatic lesson. Fortunately, the sensation passed and she did not fall on the ground. My inexperienced blunder caused little harm. (although my nerves were shot!) In the future, I was careful to test the temperature of the irrigation water and to lie the person down before putting water into the ear canal.
New Doctors and Nurses are coming to a Clinic near you!
It is nearly July and that means that a new crop of newly minted nurse and physician chicks have been pushed out of the nest. I read the tortured tweets and threads of the beautiful souls who feel dumb and inadequate during this vulnerable time. The proud perfectionists among us dread feeling this way.
If I could, I would reach out and give all the baby nurses and docs a virtual hug. The apprenticeship system set up in medical training and nursing is a rough one. We present ourselves to the unknowing patient as a professional but inside, we are filled with feelings of self-doubt and inadequacy.
I remember very well the start of my internship year at a small hospital in Northeast Philadelphia that no longer exists. If felt like the ink on my med school diploma was barely dry. Back in those days, the pockets of our white coats were stuffed with little reference books, stethoscopes, and reflex hammers. Suddenly the pen that I used routinely to write orders on the patients’ paper charts, became a much more dangerous instrument,
Would I use that pen to write the orders for intravenous fluids and medications that would bring healing and relief to some person suffering from shock or post-operative pain? Could my innocent ball point pen become and instrument of harm or suffering if I chose the wrong medication or dangerous treatment? Could my pen become a weapon? How would I know the difference?
Our system of training physicians and nurses is a massive apprentice system with new graduates stepping hesitantly into their first jobs as young doctors and nurses. Do we have to use real patients as our guinea pigs? Many medical schools have wonderful programs employing actors as patients and mechanical simulation labs. Can anything really prepare young clinicians for the real thing?
How will a real patient react when you tighten the tourniquet or pierce the skin with a needle for the first time? How do you know exactly what equipment you will need when you want to prevent that rogue drip of blood from staining the patient’s sheets.
Trainees must learn by doing it. Hopefully, young doctors and nurses will be supervised by a kind and supportive mentor during clinical rotations. Self-doubt is absolutely normal and I wrote about it extensively in the article: You are not an Imposter, You are a Human.
It does not matter where you went to school or where you trained. An element of self-doubt is an important component of succeeding in the difficult decisions and choices professionals must make. That feeling of discomfort motivates us to confirm our orders and to check our work.
It is useful to ask ourselves at some moment of conflict or frustration, “Could I be wrong about that?” What I mean is could there be another way of looking at this symptom or this sign in the patient’s presentation. Could there be an alternative to the plan I have laid out that might work just as well? Could a mini consultation with a reference work or a colleague help provide another viewpoint or solution?
Confirmation bias is a human impulse to interpret new information as being supportive of the opinions we already hold. Bias can enter our minds when a demeaning phrase used in a note, an assumption is made based on a person’s appearance, or a quick judgement made at the doorway. We search for things in the world that support the beliefs that we already have, even if those beliefs are faulty or incorrect.
You read on a triage note that a patient has headaches and prior history of migraines. You will go searching for evidence to confirm this and ignore the evidence or findings going against that diagnosis. Her current story is sudden onset of the worst headache ever. It feels different. We have a tendency to find what we are looking for. Our brains really like to be right, even if we are confirming the wrong diagnosis. We are treating migraine and missing subarachnoid hemorrhage.
Listen to your Patients
We must rededicate to actually listening to our patients. We must examine them. Physical exams matter. The healing power of touch is part of the nurse-patient and doctor-patient relationship. Our patients trust us and that is an awesome responsibility. If you are in your first few weeks of working and this feels overwhelming and a bit nauseating, it sounds like you are doing it exactly right.
For over thirty years, when I entered the room of a new patient, I introduced myself and took their hand. They thought I was just shaking their hand in greeting. I was doing that, but what they didn’t know was I was surreptitiously checking their radial pulse with my index finger. I knew without a monitor or a rhythm strip just what their pulse was, its regularity and the feel of their skin. This very innocent gesture gave me so much information.
Nurses and physicians in training will quite naturally have moments of uncertainty and will undoubtedly make mistakes. All the checklists and double signatures built into the system have been inserted to try to reduce error. If one misses an IV or a lumbar puncture, there are lessons to be learned from the experience about patient positioning and operator positioning. Any fail should be viewed as a learning opportunity.
This is so difficult to accept when we may have hurt someone or caused them to need another stick. The only way to get better at all the procedures is to do them, check them, and do them again.
Crucifying people or shaming them for not knowing something or forgetting a fact on bedside rounds is absolutely wrong. The model of learning in medicine employs a system of questioning used by the ancient Greek Philosopher Socrates. The method uses a form dialogue between the teacher and the student in which the teacher asks questions and the student attempts to provide the answers.
The questioning and probing of the true Socratic approach should be gentle and nurturing. Sadly, for some, it becomes a forum for bullying and humiliation. It is normal that you do not know about the treatment for rhabdomyolysis, yet. You do not know what that blip on the EKG means, yet. You are there to study and to soak in all the experiences. You can learn where to look for the answer or whom to call.
A while back I had a discussion with my friend Kathy Kelly, who has practiced as an emergency physician for over 35 years. She was telling me all about a patient she had seen the previous night. After all was said and done, she had no idea what was going on with the fellow. This was after practicing for 35 years!
My dear little birdies learning to fly, its ok to feel dumb. Uncertainty is part of the process that keeps you questioning and checking the references. You are inching out of the nest. Its ok to feel inadequate. You are right where you are supposed to be at the beginning of your learning journey. You are worthy and you are training to be the best clinician you can be.
