Getting to 50

By Nicole T. Jiam, Johns Hopkins University School of Medicine

About a month ago, I was sitting in on a clinical correlation led by an aneurysm neurosurgeon and his patient at the Johns Hopkins Hospital. These clinical correlations are incredible opportunities for medical school students to learn directly from the patients themselves by hearing their story and then asking them questions.

During this particular clinical correlation, the neurosurgeon discussed the importance of informed consent and the decision making process that stretches over several weeks. The decision to undergo a surgery and which neurosurgeon requires deliberation and time.

At one of the meetings prior to the operation, the Johns Hopkins neurosurgeon candidly told his patient: “One of the most important ways of evaluating physician competency is case volume. You want to pick a surgeon that has a huge wealth of experience doing this procedure.”

To which the patient responded by asking, “So… how many aneurysms have you done?”

During our clinical correlation, the patient recounted the neurosurgeon getting onto his computer. After a few minutes or so, the physician replies, “You will be my 537th.”

In the clinical correlation Q&A, a classmates asks the neurosurgeon, “What number determines competency?” It, of course, varies due to a number of factors, but 50 was thrown as a minimum number.

My classmate then re-raises his hand.

“Well… how do you get to that 50?”

It was a very legitimate question. One I had asked myself.

In these past couple of days, I have witnessed what happens when physicians fail to uphold their responsibility to their patients. Michael Skolnik was a young teenager that died unnecessarily because a neurosurgeon did not provide true informed consent. He did not disclose to the Skolniks that he had only done two cases prior to Michael’s. Furthermore, the neurosurgeon did not take the time to discuss the risks of the surgery and alternatives to the craniotomy. To Skolnik’s neurosurgeon, informed content meant a mere signature and 15 seconds of his time. A life was lost because of this missed conversation.

It was a heart wrenching story, and I felt ashamed for my profession. Telluride Patient Safety Roundtable forced us scholars to face these necessary truths. That lives are lost when we view informed consent as an annoyance rather than a responsibility we owe our patients.

But alas, we revisit the question – how do residents achieve that level of competency without endangering a patient’s life? Someone’s going to have to be number 1…

The Johns Hopkins neurosurgeon answered the question with this:

It is important to be honest with your patient. When a patient comes to me and tells me, “I don’t want a resident touching me”, I will ask him what does he mean by touching. If the patient means draping and prepping, etc., then I will let him know Johns Hopkins is a teaching hospital and that it would be better for him to seek care at a private hospital. But if he means the aneurysm/core of the case, I tell them that I will only let a resident that can do the procedure as good, if not better than me, “touch the patient.”

Residents have been frustrated with me in the past, saying I don’t let them do anything. But that’s because they cannot do the procedure at the standard I demand […] I do believe some residents can become as good as me. They may not be able to do it as quickly but they can certainly achieve the same level of proficiency […]. Aneurysms are not for everyone. I’d be happy to refer to them to a career counselor.

When I first heard his response, it was with mixed emotions. I understand how dangerous aneurysms are. But wasn’t that a bit harsh to imply a career change?

After hearing Michael Skolnik’s story, I recall this answer with fresh perspective and humility. This Johns Hopkins neurosurgeon demanded a standard of care we all owe our patients. How would I feel if a neurosurgeon killed my little brother by refusing to acknowledge his shortcomings? Yes, we all have to learn – but not when lives are at stake.

And if we’re not good enough, maybe we shouldn’t be holding the scalpel in the first place.

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About njiam
My name is Nikki.

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