Why junior doctor quality is regressing, for better or worse.
In 1962, a US woman lifted a car to rescue her baby child in an accident. This was witnessed by the now late Jack Kirby, a comic book artist. Later that year, The Incredible Hulk would appear in print for the first time, with Kirby attributing his inspiration for the character to this incident.
Superhuman feats (in this case, hysterical strength) are not unknown to the layman. Legend and mythos are the basis of communal human life. If miracles only existed in Scripture, there would be no believers. Who among us has not seen the impossible being done?
As Medicine is one facet of society, despite its contemporary status as a highly evidence-driven discipline, it too comprises of tiny people — us hairless apes — who can marvel at the improbable coming true. Despite our jobs being much alike a protracted dirge (for the lay reader planning to study Medicine, we beg you recognise that doing Medicine to “save lives” is the aspirational equivalent to doing Law to high-five the judge like Ted does in Ted 2), there are from time to time exceptional feats performed by others in our ranks which deserve some marvel.
An ancient (hypothetical) tale from a medical centre in the far North shall serve as a jump-start to our discussion.
CASE 1
A medical HO on call scrambles to a Code Blue activation in a nearby ward and discovers, to his relief, that there is already a MO on the scene. Between each cycle of compressions, the MO performs pulse checks and analyses the rhythm on the manual defibrillator before barking out commands, apparently from memory. As far as Advanced Cardiac Life Support goes, this seems to be the peak of it. The MO has already taken the bloods via femoral sampling; the HO makes himself useful by running the gas syringe to the nearest point-of-care machine, and then running back with the slip of numbers which he hands over to the MO. At a glance, the MO makes a diagnosis and dictates more plans, which the team carries out with haste.
Not too long after, there is return of spontaneous circulation, and the Registrar arrives from a different code upstairs to find nearly everything settled, and the MO asks him for a blessing to get Intensive Care on board. The curious Registrar agrees, but before he can praise the MO for the impeccable management so far, he realises that the MO looks profoundly unfamiliar, and so enquires which year of traineeship he is in. Raising a bushy eyebrow, the MO offers a fun fact which shocks both the HO and the Registrar — he is, in fact, from Obstetrics and Gynaecology, and is here on an interim posting.
Any physician not living under a rock would, rightfully, find this (hypothetical) story incredulous. A feat like this in our time seems almost (liberties taken) impossible.
Yet, against reasonable odds, these things do happen. Another (hypothetical) legend has it that in the very same centre, but more recently, an Orthopaedic MO diagnosed a STEMI in an ED patient he had been called to review for shoulder pain (he essentially discovered that the patient had been having chest pain instead, and no, an ECG had not yet been done). Pigs are growing wings and taking flight before our eyes.
The rise of superheroes
We live in an era where procedural familiarity is being dumbed down for the worse, starting from young. Juniors are becoming less daring, and seniors are becoming less trusting. One may see it as the Medicine-equivalent of the high-strung mother who refuses to let her children go to the neighbourhood playground because the slides look dangerous. Consider that not much longer than a few decades ago, medical students were forced to live in dormitories on-site during their Obstetric postings so they could complete the required number of vaginal deliveries to simply pass. Today, finding a student tagging on to any sort of call is unheard of, and the majority of students’ procedure logs are signed off without any actual witness. This culture makes for more laid-back students and, as we have discussed in an earlier piece, less-skilled HOs. And the trend is longitudinal: back then, HOs were doing Cesarean sections as performing surgeons under supervision, whereas today, you would be hard-pressed to find one a HO as a first assistant in manpower-abundant conditions.
An exception to this generality is called a “superhero”, defined by his or her “superpowers” obtained precociously in the line of duty. We can in turn loosely define a “superpower” as some competency of a physician, be it clinical or procedural, which allows him or her to function at a higher level than his or her peers. To be “superpowered” is essentially antonymous to being acopic.
Much ink can be spilled over acopia as a phenomenon in contemporary Medicine. Indeed, things are so horrendous that many juniors would not be able to pass the HOPELESS test. If we were to attempt to put all these deeds on the ground to the (hypothetical) pen, not all the books in the world could contain them. Not a single MO in a posting with HOs can possibly claim to have never encountered as least one acopic HO; indeed, few HOs, if any, have escaped working with an acopic co-HO.
Acopia can be understood as a state of imbalance where a physician’s workload outweighs the ability of the physician to complete the work. By this definition, it is possible for even the most capable physician to be acopic, if the workload is truly Herculean. Workload is the product of circumstance, and rarely correctible.
Hence, when speaking of acopia, attention is typically drawn to the physician’s capability. Capability is multifactorial. There are professional factors (attitude, knowledge, competency) and circumstantial factors, which may include personality traits, interpersonal issues, physical or mental handicap, or even environmental obstacles. All of these culminate in whether the work can be done or not.
In a realistic work setting, there can only be expectations of the professional factors. A physician must have a constructive attitude, good relevant knowledge, and decent dexterity or procedural competency. Deficiencies in any —or all — of these will invariably lead to acopia.
Take, for instance, a (hypothetical) mid-posting feedback session held for HOs in a subspecialty surgical unit. Imagine if a HO had asked in all seriousness if, supposing they were called to assist in a surgery which were to start close to 5pm in the evening, they could be officially allowed to scrub out midway, as their working hours would have officially ended. For all we know, this HO could be a dean’s lister, white horse, and even be performing better than average in typical day-to-day work. But these are of no use without a constructive attitude. Who can then be sure that the work from such a physician, should it be done after hours, will be of good quality? Is the life of grandma on the operating table at a quarter to 5 worth the risk?
Verily, the standards of work-life balance are increasing. All want life to increase, and work to decrease — a noble aspiration for those who are, perhaps, married young, and need time for their domestic life and children; less so if the alternative goal is baking or spin class or protected League of Legends time (no-hate disclaimer: we do enjoy all sorts of less noble things, including and not limited to these 3, in good moderation). The former ought to be celebrated, and given all the space and time they need (and perhaps more space, because we have government ministers with funny propositions about the critical surface area required to safely perform coitus). If the latter, however, choose to set their quality of work as a holocaust on the altar of having quality time, they are, latae sententiae, ignoble.
It is manifestly inadequate for a physician to simply aim to be up to standard, as if anyone these days can quantitatively define a standard. If we even could, it would appear that the standards are continually falling each day. Acopia becomes more pervasive. Everyone suffers.
The cure to acopia is certain: we need more superheroes.
Tales from the front lines
Let us then conduct an examination of various types of superheroes (from hypothetical case studies), how their feats improve our lives, and how we can get more of them.
For greater ease of things, and to provide common ground for these cases, we shall focus on superpowered feats attributed to HOs in recent history. If we recall that superpowers are competencies which exceed typical expectations, it directly follows that it is easiest for a HO to have a superpower, since the typical expectations of a HO are the lowest in the hierarchy. Any MO not waist-deep in a non-medical subspecialisation should be expected to run a code well, for example, but if a HO could independently manage a code for at least the first few minutes, we would not hesitate to bring him out to celebrate.
Let us begin our analyses:
CASE 2
You are a MO working a subspecialty (read: non-abdominal) surgical unit, and your HOs are a pair of local first-posters. During morning rounds it is noted that one of the patients, a man in his 70s who is functionally dependent and minimally communicative, has been spiking high fevers for the past week with no apparent source despite coverage with broad-spectrum antibiotics. The plain chest radiograph was clean. The team orders computed tomography images of the thorax, abdomen, and pelvis (CT TAP) for a better look, reminds the HOs to expedite the scan and trace up the report, and proceeds to OT for a long full-day case.
Later during exit rounds, you look through the patient’s chart, and see that the scan has somehow been done within the same day. The scan report has been signed by the duty radiologist just before you got out of OT, and reveals perforated cholecystitis as the hidden source of infection. Reading further into the day’s notes, you realise that the patient got far more than was bargained for:
The HOs had scrounged for a scan slot early in the morning. They then actively traced the images without waiting for the report, and one of them was able to interpret the scan and make the diagnosis. They both then came up with a shared plan of action. One spoke with the patient’s family and counselled for the likely solution (imaging-guided drainage), while the other called General Surgery to make the referral and bless their plans.
Fortunately, the General Surgery Registrar reviewed the images, agreed with the diagnosis. At the HOs’ request, he even assisted with the signing of procedural consent, with the patient’s next-of-kin authorising on his behalf. Meanwhile, the HOs managed to get an afternoon slot with Interventional Radiology for a percutaneous drain insertion. The patient was back in the general ward within a few hours, and would never spike a fever again while inpatient.
While reasonably impressed, you have to ask what motivated them to act independently. They explain simply that they were able to make a diagnosis, they knew the treatment, they were clear on what needed to be done, and they were also aware of the complications of delaying essential treatment — they would not wait for the team seniors’ approval as they were not counting on a swift reply, since most of them would be scrubbed in for the case in OT.
We can look into a number of details in this case, but shall lay out the most important:
- Good knowledge. The HOs were able to interpret abdominal computed tomography images on their own to diagnose a perforated cholecystitis. It would have been apparent to them that the patient’s infection could not be treated with only antibiotics, given the many days of spiking fevers, hence prompt source control would be needed.
- Good competency. The HOs had identified the problem and knew the solution, and simply needed to get it carried out. They understood the workflow needed, that is, to obtain a General Surgery consultation, and get the patient’s family on board, as it would be most expedient for the donee of the patient’s lasting power of attorney (LPA) to be present to sign the consent.
- Good attitude. A lesser HO would have sat on the problem and waited for the formal CT report to come out, and may have even waited for the team to come out of OT before asking for a plan of action based on the reported findings. These HOs clearly understood that achieving source control in hepatobiliary sepsis should not be delayed further, made a decision together to proceed with a solution where they may not receive a response from their seniors in time, and were willing to bear the consequences of this decision.
Similar things do happen on a daily basis, but with less at stake. Many Vascular Surgery units treat patients with infections, and in some centres it is established practice to get Infectious Disease on board for management once cultures and sensitivities are reported (evidence, in fact, shows that Infectious Disease consultation is a factor which improves outcomes, c.f. Tang et al.’s retrospective cohort study in Scientific Reports published in 2017). Once the labs are out, the team HOs know to independently make the referral, and amend the antibiotic regime according to the antibiogram. Conversely, in this case, where the matter in question is an invasive intervention, deciding to proceed without a senior’s cover requires an extra ounce of gut and virtue.
Sed contra, let us examine a (hypothetical) foil to this case, which turned out a little different but not much worse:
CASE 3
One afternoon in a tertiary centre, a middle-aged noncommunicative man is admitted from his nursing home for functional decline. The ED has noted that his abdomen looks really distended, blood work indicates hypokalaemia, and a plain film reveals small bowel obstruction. The surgeons have already seen him downstairs — unfortunately the patient is unable to convey if he is having any pain, and his vitals are stable, so it is concluded that the aetiology is medical, and there is no acute surgical intervention indicated. The patient is admitted to General Medicine with a nasogastric tube. He is scheduled for an overnight CT of the abdomen and pelvis (CT AP), and the case is handed over to the Medical HO on call to trace any urgent findings.
The scan is completed in the late evening. The HO obligingly scrolls through the images, which confirms the impression of ileus on gross inspection. A scan report has not been signed yet, and the patient has remained haemodynamically stable, so the HO leaves a note with a plan for the primary team to trace the formal report.
Come early morning, the images are reviewed by the incoming primary team HO and MO, who notice that the appendix is inflamed with a distinct wall defect and surrounding abscess formation. The formal report has yet to be signed, but it is now noted that the patient’s heart rate has been creeping up since the early morning, and his blood pressure is now in borderline range. On examination, the abdomen is peritonitic.
The surgeons on call are updated with these findings. Within the hour, the patient has been started on broad-spectrum antibiotics, and is being pushed to theatre. Intraoperative findings confirm perforated appendicitis with 4-quadrant pus requiring peritoneal washout and drain insertion.
The Medical registrar briefly considers whether the HO on call ought to have updated her MO with the scan images, or requested for a provisional report from the radiologist on call, on the basis that this would have allowed the patient to receive definitive surgical management sooner. The primary team HO defends his colleague by stating that, given the nature of the handover, and the tendency of the radiologists on call to screen for urgent scan findings and sign the reports sooner, the HO on call was not at fault for failing to make a diagnosis from the images. He and other HOs posit that most HOs are in fact not capable of interpreting CT scans, much less one which already a major distracting feature in the form of multiple distended small bowel loops which could have made it difficult to appreciate the abnormal right iliac fossa.
Based on these details, the team decides that the HO on call was not negligent.
In this latter case, the consequences of limitations of knowledge are made manifest. It is a fact that the majority of HOs cannot interpret CT scans without the aid of a radiologist’s report, and we must work within this reality. It is a different question as to whether this ought to be the case. At least one local medical school recognises that we ought to expect more, because in the Case Analysis (i.e. long case) portion of their final Surgery exams, medical students are often made to interpret ultrasound, CT, or MRI scans. For example, they ought to be able to identify a hepatocellular carcinoma if they are shown a multiphasic CT, instead of just listing out the features by rote in a Modified Essay Question. Indeed, the latter student may be a good student, but a worthless physician in practice. Ironically, if we ever saw a HO actually correctly interpret a multiphasic CT as such, we would probably ask them — almost seriously — if they were gunning for Radiology. This attests to the true situation on the ground in spite of efforts directed to the contrary.
Nevertheless, returning to this case, it may very well be that it is difficult for a more junior physician to make a new diagnosis on top of an existing distracting pathology occupying most of the scan area. Moreover, the HO in this case passes the HOPELESS test (and so does not deserve a scolding; she also passes the Bolam-Bolitho test). We can thus conclude that she was a good citizen, but sadly — albeit entirely fairly — not a superhero.
Next, let us evaluate a different aspect of a physician’s professional ability in the exercise of superpowers.
CASE 4
A Surgery HO on call is called by a nurse to attend to an unruly patient who is running around the ward screaming in pain. He had a Foley catheter in situ which he had transected with a pair of scissors, for reasons known only to himself and God. The HO can hear the patient in the background, and realises that it is indeed somewhat urgent. A quick glance at the rounding notes informs him that the patient is on continuous bladder washout (CBWO) for gross haematuria likely secondary to a bleeding tumour in the upper urinary tract. With the obvious diagnosis in mind, the HO instructs the nurse to shut off the CBWO inflow, and races upstairs.
Reaching the ward, the HO manages to calm the patient down with the help of generous intramuscular analgesia (he had yanked out his IV cannula in the chaos) and proceeded to assess the damage. With the help of his friend the ward’s Medical HO, he obtained an ultrasound machine and found the bladder massively distended with clots, the Foley balloon still in situ. The patient is still agitated and it is clear that something needs to be done immediately.
The HO begins to counsel the patient for a manual bladder washout (MBWO), while his friend secures new IV access. The patient agrees, ostensibly believing (wrongly) that nothing could be more painful than his current urinary retention quagmire. A pair of nurses are dispatched down to the OT and ward store-room respectively to retrieve the needed items, including a large-bore Nelaton catheter, a large bucket, and the ward’s entire supply of bottled saline. Meanwhile, the HO has limited success in relieving the bladder distension with intermittent suction through the existing (sliced-through) Foley, but manages to keep the patient happy long enough.
Once a trolley is prepared with the required items, the HO proceeds with the MBWO, assisted by a single nurse. Despite generous multimodal analgesia the patient still screams and squirms over the next 3 hours, during which at least 2 floors of the peripheral hospital are depleted of their saline supply, and the team needs to switch to sterile water for the last stretch. But a bucketload of gnarly clots later, the HO finally obtains clear returns, re-applies the 3-way Foley, restarts the CBWO on fast flow, and slinks away to catch up on 3 hours’ worth of overdue reviews.
Because of the intensity of the situation, it never occurred to anyone to contact the stay-out Urology MO, who likely remained fast asleep at home and only came to know of this cinematic altercation the following morning on rounds.
Many would feel that the ability to perform a MBWO cannot possibly be a superpower.
Unfortunately, as things have it, we felt obliged to accurately define a MBWO in this case study. Far too many HOs in practice can be seen simply flushing the 3-way Foley with a feeding syringe, and documenting it as a MBWO. The most obvious implication of this is that the patients who receive a “MBWO” invariably get obstructed again before the day is up, because all flushing a Foley does is dislodge the clots which are immediately obstructing the outlet of the Foley tip. Whereas, an actual MBWO dislodges and extracts all the clots present in the bladder. A HO who settles for a fake “MBWO” is not trying to solve any problem, simply delaying the problem to be handled by the next HO who takes over.
As much as it may appear like an attitude problem, it is actually one of competency. Because of this culture of not doing proper MBWOs, or leaving it to the Urology MO on call to handle, few fresh HOs or SIPs get to observe it in practice. The maxim of see one, do one, teach one is often abused by quoting an imaginary scenario that a relatively inexperienced practitioner is forced to perform a procedure he or she has only observed before. Yet for the vast majority of simple bedside procedures, this is not truly the case, as a physician should have requisite knowledge of the procedure which is instantiated during direct observation, and ideally even more so in supervised practice.
Most medical students are aware that a MBWO exists. At least one local medical school (or its clinical tutors, at least) routinely stresses to medical students that it is important to know how a MBWO is done. Discussing how one is done is even a fair OSCE scenario. Yet, many go through medical school and HO year having never directly observed a real one, and thus would never know how to do a real one.
Performing a MBWO properly is among a long list of many lost skills which HOs should have (thereby making it a superpower), but which time and misadventure have taken away. After all, it could hardly be called a superpower if the HO were to be liable for any procedural complication. If he had read the patient’s notes wrongly, and the patient’s gross haematuria were instead secondary to a friable bladder wall tumour, the Nelaton could have just as easily perforated the bladder, leading to a far more disastrous outcome. This possibility, however, does not mean that the procedure should not be attempted by a HO. The practice of Medicine would grind to an unceremonious halt if we began to be fatalistic about potential complications of every intervention.
A HO who can independently and definitively manage a blocked CBWO, therefore, is a superhero. This can be extended to any other “lost skill” that HOs can perform, but don’t commonly perform anymore. A HO, if trained and trusted, is more than capable of ultrasound-guided venepuncture, or first-line management of stable arrhythmias, or performing a trauma screen and clinically clearing the cervical spine for a patient involved in an inpatient fall, or running a Code Blue beyond the initial 5 minutes. The ultimate superpowered state is when a HO becomes capable of performing any function which does not legally require the presence of a MO. It is unfortunate that such HOs cannot also learn the ability of bilocation (which is not a lost skill outside of sainthood), which would guarantee their MOs a good night’s rest each call.
Falling from grace.
Our analysis cannot ignore the fact that some of these superpowers have ceased to exist for compelling reasons. Let us explore one hypothetical example, a tale originating from quite a long time ago.
CASE 5
A patient is admitted to the obstetric antenatal ward at a premature gestation for a complication which requires inpatient monitoring. Overnight she complains of new-onset abdominal pain and bleeding per vaginum, for which the obstetric HO is called in to review her. The HO assesses the patient and performs a vaginal examination (VE), from which she documents that the cervical os is closed and long. The midwife assisting her uses a handheld ultrasound transducer to attempt to auscultate the fetal heart. She is unable to detect it.
A presumptive diagnosis of fetal distress secondary to suspected abruptio placentae is made. The ward activates the obstetric code, initiating a workflow that results in the patient being consented for a “crash” Cesarean section wherein there is a present danger to the fetus in utero requiring delivery within the next 12 minutes. The Registrar and MO are called out of the Labour Ward and into OT. As is usual protocol for emergency cases, a time-out is not called, and time is not wasted in repeating the VE or attempting to detect the fetal heart. The anaesthetist puts the patient under, and the surgeons begin knife-to-skin.
Shortly after entering the abdomen, the Registrar surprisedly observes that the uterus does not look quite right. Swallowing hard, he directs a nearby midwife to inspect the perineum — the baby is, in fact, crowning at the introitus. A normal vaginal delivery proceeds with the baby giving a strong cry at birth, and the half-dead MO is left to close an abdomen which did not need to be opened in the first place.
As it turns out, the HO did not, in fact, know how to perform a VE. As it happens, (contraction) pain and (showy) bleeding are perfectly normal cardinal signs of labour. And it is understandable that a fetal heart cannot be auscultated blind when the fetus is already halfway out of the mother.
To our knowledge, as of today, no obstetric centre in Singapore allows HOs to perform VEs in labour (or at least does not allow labour management to depend on their VEs). Similarly, alluding to the previous case, many Urology MOs may not trust a HO to document or perform a MBWO. In at least 1 specialist centre here, no one except Anaesthetists are permitted to perform ultrasound-guided venepuncture. Compounded over time, these skills become lost at the junior level.
There is a grain of rationale in this trend. Some things are too sensitive, or too technical, to be entrusted to juniors. This is true in settings where the juniors are most likely to be unable to perform these tasks. An example of this in Surgery is flap monitoring, which the vast majority of new General Surgery HOs would not know how to do, unless already taught how to do so by another HO or MO; an example in Medicine is performing a bone marrow aspiration. Tasks in this category are specialised matters which are not practically taught in any medical schools or teaching hospitals, local or abroad.
Yet this is the limit of the rationale. These things are already instinctively handed over to MOs instead of HOs after hours. There is already no way for HOs to come into contact with these tasks; while the MO sorts them out, the HO is presumably busy fighting fires elsewhere.
Even so, many things escalated to MOs on call are things which HOs are perfectly capable of doing. The supply of possible examples is a diabolical cornucopia of half-ignored Teams messages and includes things like nasogastric tube placement CXRs (despite every locally-trained medical student already knowing how to do this), choices of antibiotics in patients with straightforward infections (despite every hospital having inpatient protocols for this), or help in managing a patient who has not even received an initial review.
For the most part, this can be attributed to a fear on the junior’s part of being held personally accountable for an intervention; the junior knows that by having documented that the decision was discussed with the senior, the senior will bear final responsibility. For a HO just starting work, and not familiar with certain local practices (for example, whether to send off serum lactate with a full septic workup), this is permissible. For a HO in a posting with sensitive patient types, such as Paediatrics or Obstetrics, this is expected. But this is not transferrable to general practice. It is an instinct of self-preservation, not a clinical skill.
For a HO in a second or third posting, a reasonable degree of initiative is to be expected. This includes maintenance of adequate knowledge of what medical school has covered (be it MBBS or MBBCh BAO), in addition to familiarity with local practices (for instance, Clinical Practice Guidelines for Diabetes and Hyperlipidaemia). At this point, in contrast to the medical student-level platitude that there is no such thing as a stupid question, a physician must start acting like a physician instead of just a senior’s secretary. Questions asked, and help solicited, ought to be truly something beyond the HO’s reasonable knowledge or ability.
The journey to this stage requires a balance of 2 factors: opportunities to learn from, and keenness to learn. Of these, the former is more important. Adverse circumstances can drive even the laziest physician to a semblance of competency. Lack of learning moments, on the other hand, deprives even the most enthusiastic of physicians of the means to instantiate their talent. To allude to one of our cases, even the most talented and knowledgeable Urology HO, through no fault of his own, will be unable to do a MBWO independently if he has never laid eyes or hands on one being done before.
Conversely, it is also true that a physician who is pathologically lazy can turn circumstances to his advantage and ensure that he is as far from such learning opportunities as possible. Consider this example:
CASE 6
In a certain medical department, there is a directive that HOs need to be specifically certified for the task of drawing blood samples from peripherally-inserted central catheters (PICCs). This policy is an institutional effort to reduce the risk of line infections, as well as that of accidentally diluted samples being sent to the lab.
Nurses are also not allowed to draw these bloods. When a patient with a PICC is scheduled for a blood draw, the practice is for the nurse to trigger this to the HO in charge of the patient. The alternative would be for the nurse to draw the bloods peripherally (that is, to not use the PICC). But patients with PICCs often do not have the best vascular access, and taking peripheral samples when there is already a perfectly functional PICC is a cause for unnecessary pain to the patient.
The HOs in this centre are called to attend their PICC workshop in batches, upon completion of which they will be certified to perform PICC blood draws. Many grumble about having to attend this: after all, in their previous postings, they have already been taking blood from PICCs without a need for certification. These HOs simply carry on with their day to day work, inclusive of helping nurses perform PICC blood draws, and hope that nobody audits their certification.
One of the HOs refuses to attend for a much different reason. The rationale is simple: being certified for something just means she is capable of doing more work, and so more work can be demanded of her. When asked by a nurse to assist with blood drawing from a PICC, she has the power to decline as she is not certified to do so; instead she deflects the work back to the nurse, telling the nurse to find another HO or MO willing to do it, or to take the bloods peripherally.
As mentioned in a separate discussion, industriousness is a keystone virtue in the practice of Medicine. It is the Platonic mean between overwork on one extreme, and sloth on the other. The vast majority of physicians come to have a functional level of industriousness through enduring each day’s work, learning slowly, and purposefully improving personal and institutional practice. With this continual upward evolution, acopia gradually becomes the exception rather than the norm.
There will still endure a minority of physicians who spurn learning opportunities, and care little for the quality of their practice. These physicians are dangerous if left to their own devices with patients. In a perfectly functioning training system, these physicians will have their inevitable malpractice and acopia flagged out, get censured in their appraisals, be continuously recycled through probationary postings, and eventually be transferred out of clinical sight and mind, or even asked to seek alternative employment. In our real-life imperfect system, a good number slip through the cracks and remain in practice.
The real and present hazard that we face is that both inadvertent and deliberate acopia are being more tolerated in the name of sensitivity. This lowers expectations of juniors on a widespread scale, which in turn affects the system’s ability to filter out the ones who should truly not be practicing Medicine, particularly those who are deliberately acopic. We may have not yet observed any loud sentinel event, but the standards are dropping, and it is only a matter of time.
The formula of resurgence.
Not all is doom and gloom. A good majority of junior physicians have zeal to learn, and do not hide from work. They recall a sliver of what motivated them to enter the profession in the first place, and have set for themselves personal standards which keep them up to task. Some may believe in God — a certain but not terrific motivator, depending on how fickle the God and physician in question are (Hippocrates’ disciples made their oaths to Asclepius, and they haven’t murdered anybody we know of through malpractice). And obviously, they see their patients as human beings, and therefore their jobs as a predominantly moral, not technical, affair. Unavoidable mistakes, as in our 3rd case here, are seen with regret, and learned from, such that they will never be deliberately repeated.
All of these qualities are present in our superheroes. There are several additional key features: they must be functionally trustworthy, and they must be revealed to be equally competent in skills outside of their specific interests.
Functional trustworthiness is the key opposite trait to acopia. It means that a HO can be trusted to work completely independently, without a MO needing to double-check their work. If a MO does come to it, it typically will be a waste of time, since everything is already in order as the team requires. This further means that when this HO escalates a matter to the MO, clinical or otherwise, the MO will know to see to it with prejudice, as it indicates that the HO has already exhausted all means within his ability to manage the matter. Oppositely, if the MO were to ask the HO to do something, the MO can consider it done. The ability to achieve this level of function is itself a superpower.
Competency in basic clinical skills is to be expected — there should rarely be escalations for IV cannulations, blood draws, blood gases, bladder catheterisation, simple troubleshooting of surgical drains, interpretation of plain imaging, or interpretation of 12-lead electrocardiograms. The next step from here would be learning more advanced skills such as ultrasound-guided bloods, interpretation of tomographic imaging, MBWO and CBWO set-up, interpreting special electrocardiograms (including placing the leads, such as for a right-sided electrocardiogram), performing point-of-care ultrasound, and others. Individually, and in gradation according to rank and experience, these are also superpowers, but the surest way to call it a superpower is if the skill is not typical of the physician’s specialty. Any Cardiology MO can ultrasound the heart to estimate ejection fraction, but one would never expect a General Medicine HO to do it competently until they see it. Any Obstetrics and Gynaecology MO can perform a basic obstetric ultrasonographic assessment, but if a (real — just kidding) Surgical MO were to demonstrate one, it would be good reason to be impressed. Any Paediatric HO can set a yellow IV cannula into a toddler under torchlight-assisted visualisation, but any other HO doing it would be something to see. And, for the most mind-blowing example, no one would expect an Orthopaedic MO to interpret an electrocardiogram, until one actually diagnoses a STEMI.
There is one final factor that we ought to take ownership of: a superhero requires a good senior to exist. There is no room for a HO to be any semblance of “good” beneath poor leadership. In our final case, we shall examine a positive scenario, also relatively (hypothetically) recent:
CASE 7
A General Medicine team comprising the Associate Consultant (AC), MO, and HO are doing exit rounds from the doctor’s counter in their ward. A nurse alerts them that one of their patients has become hypotensive on the latest vitals check. The HO proceeds to check it out while the AC and MO continue.
Some minutes later, they hear the HO issuing instructions loudly from the offending cubicle, followed by a Code Blue alert. The patient in question is a previously-well gentleman in his 70s, for full active measures. The AC and MO sprint over to find the crash cart being pushed to the bedside, a nurse doing compressions, and another nurse slapping the right antecubital fossa with a medium-bore cannula ready to go in.
The HO has applied the pads to the patient, had taken up position at the head of the bed with the bag-valve mask, and has instructed the nurse standing by the bedside to switch the defibrillator to manual mode — the nurse is unsure, so the AC takes over by the cart. The HO correctly identifies pulseless ventricular tachycardia from her position and successfully coordinates delivery of the first shock. The AC, meanwhile, has found her own IV access at the left side, and is pushing Epinephrine and calling out the timings. The MO, an overseas graduate not yet trained for Advanced Cardiac Life support, helps by running the arterial blood gas off to the laboratory.
With saturations continuing to fall despite the bag-valve on full blast, the decision is made to establish a definitive airway. The HO, from her position, calls for the tube by size, and declares that the team will proceed with a crash intubation. The AC allows this to proceed, continuing to keep time and deliver drugs. The airway kit in the ward does not have a fibre optic-assisted blade, so the HO gets the endotracheal tube in under direct visualisation. Placement is confirmed on auscultation and capnometry, and is completed even before the MO returns to the bed.
There is return of spontaneous circulation, and the patient is pushed to Intensive Care within the hour. He lives.
This case would have turned out very differently had the AC told the HO to step aside on account of her rank. Many would have done so, or forced the MO to take over, or even waited for the Airway Team before intubating. The prudence of this AC permitted the HO to demonstrate the superpower of running a Code, effectively with minimal supervision.
This applies to all aspects of work. A MO on call could easily force their HO to see all their new cases for them, despite all new admissions needing to be cleared by them, and have an unreasonably high threshold to respond to escalations. This mounts an unreasonable amount of work on the HO and stifles them from thriving, even if they are already highly capable at baseline. A good MO is one who fulfills the innate responsibility of a senior to foster their junior’s learning and welfare, regardless of circumstances.
A good MO does not feel that it is beneath him to help his HO with HO-level tasks. Neither does he leave his HO unsupported in difficult situations which may theoretically not require his presence, such as difficult patients and their families. These ease the time and head-space of the HO to perform greater feats — feats which the MO must demonstrate for benefit of the HO. See one, do one, teach one.
This is a hermeneutic of continuity from how a student or SIP should grow in the presence of a HO or MO willing to teach. It can benefit any junior at any competency. At the very least, a mediocre junior can simply try to imitate a more skilled senior — a la Oscar Wilde, imitation is the sincerest form of flattery that mediocrity can pay to greatness.
A more industrious junior can naturally do more. Great HOs, as we can observe daily, do not simply imitate, but proactively come into their own, and formulate their own unique methods of practice, guided by evidence and no shortage of their own experience. The ability to analyse the technique of an intervention, and ponder over how it could be done better, reflects true understanding of it.
Perhaps the evil of acopia will never be totally eliminated, be it a factor of invariable circumstance, or bad physicians, or both. But with superheroes on our side, and supplanted into the ranks of our juniors, we may not be overcome yet.
To wrap this all up, we provide herewith the idiotically simple formula of what it takes to become a superhero, as follows:
- You want to be one.
- Your seniors are helping you to be one.
- You have the opportunity to be one.
If we all embodied this, there would never be a dull day at work.
on room air 