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How Experience Impacts Our Practice

 

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The industrialization of health care is a sobering phenomenon. We have been a craftsman-style industry with apprenticeships “practicing” medicine based upon experience, word of mouth and my all-time favorite, the IGBO. You might be wondering what the IGBO is.

It’s the ever-famous approach to the practice of medicine, in which we change our practice based upon our prior experience: I Got Burned Once.


This feedback loop of learning behavior sounds reasonable and appropriate and is what the ideal learning situation should be: correct. You try something, it works or it doesn’t, and based upon that learning you either repeat the behavior or you don’t.

The IGBO takes negative feedback to a new level. It is an exaggerated response to a stimulus and hence the fuller expression of self-testimonial in which “I Got Burned Once” and I will never let that happen again! The IGBO may have been an attending embarrassing you on teaching rounds 30 years ago, a missed diagnosis a week ago or any variety of individual one-off experiences from which we learn. 

However, unlike a simple paramecium or a single-celled animal, we have higher learning skills.


We are capable of separating anecdotal isolated events from the science of evidence-based health care, right?


Years ago I saw a child in the emergency department with a bad otitis media. The child had come to the ED twice as the ear infection was not getting better and the parents did not have a primary care physician. I looked the infant over, and felt a spleen that seemed enlarged. Contrary to most ear infection presentations, I ordered a CBC and found the child to have leukemia. Thus my colleague who had first seen the child was burned with a failure to diagnose. Were he and I to now start doing CBCs on every child with an ear infection? The answer should be no, but sometimes we bend to the circumstances. 

I remember a 19-year-old young lady who presented to the ED with atypical chest pain. She was sent home in good condition by her doctor only to later to be diagnosed with a small myocardial infarction. It was subsequently determined that she was a Down syndrome mosaic with undiagnosed congenital heart disease. 

Clearly this was an extremely unusual situation and should not be used to routinely conduct genetic testing upon all 19-year-olds. Instead, we should learn from it, course correct as necessary and avoid the creation of wholesale practice changes based upon one-off scenarios. In performance improvement language we call these “special cause variation events” and they should not be used to establish new practice patterns.


Instead, let’s practice to the science and not to the rhetoric, the fear, or the emotion.

 

Now I know some of you are thinking about malpractice and defensive medicine. I will grant you some of that, but not as much as you might think. If we establish the medical standard, and we practice to it, we in fact lower our liability. It is when we do one-off interventions that we open ourselves to greater liabilities. I am not naïve, and I realize the enormity of what I am asking. However, I think it does us all well to remind ourselves of this obligation. Let’s send the IGBO activities the way of the dinosaur.    


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How Experience Impacts Our Practice