We have all heard the expression about how great a "teacher" experience is.
Yet in medicine we also are constantly encouraged to practice "evidence-based medicine" and not rely on experience in medical decision making.
Evidence-based medicine (EBM) refers to using data, generally gained from what is considered gold-standard research studies, or randomized controlled trials. It tells us about groups of patients and how they can be expected to respond to certain treatments. In another post I will discuss more about EBM and its potential limitations. Doctors are extolled and expected to use the available evidence when they are planning a diagnostic evaluation or embarking on a treatment plan for a patient. But what do you do when there is no evidence? What do you do when you are treating a new disease, or one that is presenting in a very odd way? Can experience help you in that circumstance?
Experience with my camera in the past helped me get this action shot (below) of a Mockingbird trying to chase a crow away from her neighborhood (and her newly hatched chicks). She is protecting her nest. I heard the commotion, quickly grabbed the camera, adjusted the white balance for sun, set the shutter speed for very short time to catch the action, a relatively low ISO as it was quite bright, and then tried to get an in-focus photo in a short moment.
I was lucky.
I caught it. I have never taken this precise shot before. But was it luck or was it being able to use my prior experience in a new situation in order to achieve a pretty good result. I need a LOT more experience before I can be a master photographer.
And I may never be that. I am not sure I want to work so hard to be able to be a master photographer.
But I would love to be a "master clinician"
Mind you, I am not claiming to be one. But it IS something to which I have always aspired. Does the master clinician simply memorize all the evidence on a particular subject? Would someone who could answer all the medically-oriented Jeopardy questions correctly qualify as a master clinician?
Knowledge is not enough. Knowledge must partner with experience to produce mastery.
In the event that there is something going on with a patient that is novel, not described in the scientific literature, and requiring rapid or immediate treatment, it might be just the clinician and the patient. (Even if there is evidence, it still all boils down to the clinician and the patient, and choosing the right evidence to apply to that patient). This is where experience comes in.
I will tell you a story about a 12-year old girl I treated during my first week as an attending physician, shortly after finishing my fellowship in pediatric critical care.
I received a call from a local pediatrician who had a 12 year old girl with what he thought was toxic-shock syndrome (TSS) at an outlying hospital. TSS had been recently described, and at that time was known as a disease process caused by a toxin produced by a certain type of staphylococcal bacteria (we now know it has other causes as well). I knew all about TSS, as it was well-described in the medical literature. So I felt prepared to provide care for this girl. I had cared for other children and teens with it during my fellowship.
When she arrived in my PICU, she seemed to fit the syndrome. She had a high fever, was beet-red all over, and had a low blood pressure. I started antibiotics and used fluids and drugs to support her blood pressure, and I placed a variety of monitoring lines. Because her throat was very red, I ordered a throat culture. She responded to my initial therapy. Recognize that much of what I was doing was pretty much the standard way to treat shock then, and still is. Once I was comfortable that she was relatively "stable" I went home, leaving her in the care of my very capable nurses, and a pediatric resident.
When I arrived the next morning, I examined her thoroughly and discovered that I could not feel a pulse in her right wrist, although her blood pressure was normal and her other pulses were strong. On closer evaluation, the color of her whole hand seemed pale and gray. I had no idea what was happening, and called the "hand service" to help in evaluation. They discovered that she had a problem with the pressure inside her right arm being too high- a phenomenon known as compartment syndrome. She went to the operating room to have the pressure relieved. There it was discovered that her muscles in her arm were loaded with bacteria. By that time we knew that the throat culture from the day before, as well as the blood cultures were growing beta-hemolytic streptococci, the typical cause of strep throat. The bacteria showed sensitivity to the antibiotic she was receiving. Although this whole situation seemed a bit odd at this time, I was not concerned. After all, we knew the bacteria and how to treat it, and I knew well how to support a critically ill 12-year old with standard critical care supports.I had no idea how her arm muscles became so full of bacteria. But the rest of her seemed to be responding and I was certain that over the next 24 hours she would be out of intensive care.
Ah, if only bacteria and children could read the medical literature and follow it.
By the next morning, she had lost the pulse in her other arm, and although her blood pressure was good, the pulses in her legs were feeling much weaker. The surgeons brought her back to the operating room, to check the status of her limbs and check on the area they operated on the prior day.
an hour or so into her OR stay, I received a STAT page to the operating room. There, stood 5 or 6 surgeons, telling me that the only way to save this girl's life, would be to amputate both of her arms and her legs, since they had found the same situation as the day before in EVERY muscle in every limb they examined.
I was the attending of record. I had to decide what to do.
Yup, me. I was just out of my fellowship, and in an institution where no one really knew me yet. I was in charge with no "safety net" for the first time in my life. I had no time to go to the literature (at that time in history it would have meant a physical trip to the medical library), but it wouldn't have mattered. There was no written evidence concerning this problem. It was new. It was one of the first-ever occurrences of "flesh-eating bacteria" in a previously healthy person without any risk factors. This was more widespread than any described case of myositis (infection of muscle) that I was ever able to find when I did subsequently look it up. There was no precedent of successful treatment to follow. But in my heart, I could not imagine the life of a 12-year old who would have to live a life with no arms or legs.
I asked the surgeons to check the muscles on her abdominal wall and her back. They, too were involved. So what good would amputations do? None, really. Then the thinking, and the use of experience, and knowledge of my new institution started to play a more essential role. Through a number of conversations, phone calls, consultations and much wringing of hands, we (actually I) decided, with the input of the family, to try something new, undocumented, and without evidence. We were going to try hyperbaric oxygen therapy. Luckily we had a large hyperbaric chamber which could handle a critically ill person, even on a ventilator, and with a critical care nurse to provide ongoing bedside care.
The point here is not for me to teach you all about hyperbaric oxygen, or how it works, but the point is, that experience taught me we had to do something other than the "tried and true" approach to a more localized infection of this type--amputation. It was not easy. I was accused by some of practicing voodoo, of doing things that were unproven. Yup, that is what I did. But I did it openly, with total parental involvement and agreement. They knew their daughter might die, no matter what we did. This was out best chance.
Would I be telling you this story if I had guessed wrong? Not sure, but in any case, it worked. I believe she was in the hospital for months. But she lived, and kept all of her arms and legs.
This is how we learn from experience. Not by just trying things randomly, but by making sure we know the evidence, and we know when the available evidence does not fit our patient.
So truly, KNOWLEDGE + EXPERIENCE = WISDOM
Turning your experience into wisdom just might be how one becomes a master clinician.
bottom photo: original photo