The patient grimaced when she saw me. “What are you, sixteen or something?”
I opened my mouth to answer but quickly stopped myself. Telling her I was twenty-two, I realized, would not come across as much more comforting.
“Ilana is very good at this,” my phlebotomy instructor said, coming to my defense.
My patient continued to look skeptical. We started talking, and I learned she was fifty years old and had a phobia of needles. It was one she had all her life. There were points when her anxiety about it became so bad that she skipped recommended check-ups.
I tried to reassure her. I explained exactly what the (very short) procedure would entail – a tourniquet, an alcohol wipe, a tiny prick, a Band-Aid, and it’s over. I showed her the butterfly needle I would be using. I showed her the one vial that would collect the blood. I tried to make each step sound as non-frightening as possible. She nodded along.
The bigger challenge was convincing her of my competence.
“But will you get the vein?” she asked? “Sometimes they miss, and I can’t stand that, I just can’t.”
I told her that while I couldn’t make any promises, I had done this many times before, and it was very unlikely that I’d miss.
After a few more comforting words from my end, she grudgingly stuck out her am and looked away, covering her eyes with her free hand. I held her wrist to steady her shaking arm and carefully made a gentle poke.
Unfortunately, the tiny flash of blood I was so used to seeing didn’t show.
It was my year off between college and medical school, and I was working as a clinical research assistant at a military hospital. One of our studies involved collecting patients’ blood for genetic analyses. Fortunately for me, the phlebotomists at the hospital were happy to train me.
I needed fifty successful sticks to be able to do them on my own, without supervision. After watching an instructional video and practicing on a dummy, the phlebotomists I would be working with each generously offered me an arm (or two). I had maybe four or five successful blood draws under my belt, and one or two failed attempts.
All of this started at 7 AM. By 10, my instructor said:
“This will be your station. It’s already set up with needles, tourniquet, alcohol wipes, gauze.”
I looked at them dumbly. “Oh! So I’m going to do this on real patients now?”
I can’t imagine what else I expected to happen. In a few hours, I had exhausted all my training resources; this was the natural next step. But the thought of unleashing my inexperienced hands on unsuspecting patients filled me with apprehension.
“You’ll be fine,” my instructor said.
Doctors use their minds and hands. They think through problems, and they perform procedures. What makes medicine different from other hands-on professions is that the recipients of the procedures are human beings. How can there be an ethical way to practice?
The answer used to be live animals. Before the 1980s, surgeons-in-training practiced on live dogs. They then switched to pigs, which were believed less likely to incite protests from animal rights activists. They were wrong. In 1994, 77 out of 125 medical schools in the U.S. practiced live animal surgeries. By 2011, only seven remained. Many medical schools cited the draw of new, better techniques as the reason for the decline, but it’s hard to deny the influence of lawsuits and bad press, too.
Today, the big thing is electronic mannequins, which look and behave strikingly similar to real patients. They ask for help. They tell you when it hurts. Place a stethoscope over them, and you can hear heart and lung sounds. There are even ones who give birth. A 2011 survey by the Association of American Medical Colleges found that over 90% of 89 medical schools that responded used mannequins in their teaching.
And they are indeed memorable. My first experience with a simulator was my very first week of medical school. He came to the fictitious emergency room complaining of chest pain. A group of us huddled awkwardly around him, asking him questions about when it started, what he had been doing, and what his other symptoms were. When we exhausted our questions, we ordered a chest X-ray. Meanwhile, his blood pressure began dropping dangerously fast. “I’m not feeling so well docs…” he kept saying breathlessly. Unsure what to do, we stood around even more clumsily, telling him we were working on it but actually watching him die, clueless on how to stop it.
No doubt, the technology is a tremendous help in easing us from textbooks to people. But no matter how much we practice on the non-human, there will inevitably come a time when the next step is a living, breathing person. There is no way around it.
When the flash of blood didn’t show, I looked at my patient’s face. Relieved to see she was still shielding her eyes, I delicately began to move the needle around under her skin, searching for the vein that had rolled. I didn’t want to have to stick her again. I needed to get it before she noticed.
I failed. “Why is isn’t it over yet?” she asked, and at that moment looked over. I was bent over her arm, maneuvering the needle.
“Get it out!” she cried.
How do medical students decide when to keep trying, and when to quit, after a botched attempt?
In 1993 two medical students at the University of Pennsylvania surveyed third-year students about ethical dilemmas they faced on the wards. One recurrent problem involved performing procedures the students felt unequipped to handle.
“I was on call with an intern who was inundated with admissions,” one student wrote. “She asked me to see a patient and insert his intravenous catheter. After two unsuccessful attempts, the increasingly irritated patient snapped, ‘Do you know what you’re doing?’ I thought to myself: Should I try again?”
In similar situations, the authors noticed, students’ internal guidelines for when to quit varied widely. Some operated according to the principle “try, try again”; others “weighed their chances of success against the patient’s discomfort”; and still others “admitted that their decisions were based in part on how they thought the residents would react… including how it might affect their evaluations.”
The familiarity of these stories, nearly two decades after they were collected, is telling. Despite the near universality of the ethical dilemma, there exist no clear standards on how to behave appropriately in such situations. Compounding the problem is that different teaching hospitals vary in their cultures and expectations from students.
We like to think that moral deliberations are done thoughtfully and judiciously, but the reality is that outside influences play a role. Fear of looking bad in front of superiors, the desire to be seen as a team player, and the need for good grades are all factors that calculate into students’ reasoning.
Medicine involves teams. It involves hierarchies. Medical students answer to residents who answer to attendings. A side effect of this system can be influenced moral decision-making.
My phlebotomy instructor took over, while I stood back and watched. I felt clumsy and useless, just like I would a few months later when I would helplessly watch my first mannequin flatline.
When it was over, the patient shot me one more dirty look and left, cursing under her breath and massaging her arm.
I felt ashamed – not so much that I missed her vein, but that I worked so hard to convince her it wouldn’t happen. How much of that was honest? And if she was so afraid, why didn’t I just let my more adept instructor do it in the first place?
Probing why I acted the way I did, I later realized it was a combination of things. At the time, in my head, having done thirty or so needle sticks before her did feel like a lot. As my successes had grown, so had my confidence. I was even more egged on my by instructor’s praise. When she said, “Ilana is very good at this,” I was flattered, so I wanted to believe she meant it. When I said it was unlikely that I’d miss, I wanted to think, for my own ego’s sake, that it was true.
And – even though I wasn’t being graded or evaluated – I was, like the other students, spurred by the subtler pressures of wanting to look good. My instructor seemed to respect me, and I was eager to maintain her respect. I didn’t want to seem dependent, having to call for backup whenever I had a difficult patient.
I exaggerated my competence in my eagerness to be competent.
Interestingly, others probably would have defended me. There are medical professionals who have contended that exaggeration is a necessity of training, and they are upfront in telling this to the public.
Surgeon Atul Gawande called it the “physician’s dodge” and famously argued that it is inevitable.
“Do we ever tell patients that, because we are still new at something, their risks will inevitably be higher, and that they'd likely do better with doctors who are more experienced? Do we ever say that we need them to agree to it anyway? I've never seen it. Given the stakes, who in his right mind would agree to be practiced upon?”
Oncology nurse Theresa Brown backed this up in the New York Times.
“We don’t usually tell patients when we are practicing on them because it makes them hesitant and nervous, but they often figure it out anyway. If they ask, we don’t lie, but we try to answer in a way that puts them at ease.”
But patients have a different perspective. The most popular commenters on Ms. Brown’s article, for instance, were not pleased.
“I am perfectly willing to be a guinea pig for many routine medical procedures that demand training, including drawing blood. And I have never refused to have a medical student present in an examination. But that willingness stops when medical professionals are not honest about what they are doing.”
And who can blame them?
I realize that drawing blood from a patient’s arm is about as simple as it’s going to get. Phlebotomy is one of the most routine invasive procedures, risking comparatively little harm if done incorrectly. If the choices on the two ends of the spectrum are complete honesty and forging ahead by concealing inexperience, with phlebotomy we can safely practice the former. For as the comments on Ms. Brown’s piece indicated, even if one patient says no, there will be many others who say sure, go ahead and practice on me. To the patients who are generous with their arms and their willingness, I thank you.
But my near future tells of intubations and central venous lines. The question of transparency will only magnify. If my plan going into it is complete honesty, I can easily envision a situation where every patient – quite reasonably – refuses to be practiced upon. Then what?
Everyone in the medical profession goes through this. Even if they practiced on simulators first – even if they worked under close supervision – everyone had a first patient, and a second, and a third. That holds for every doctor, every surgeon, every nurse, from the simplest to the most risky procedures.
But how to handle it remains unwritten. While I’m sure there are a few who err toward complete openness with patients, most seem to be of the opinion that if they did, no one would get trained. Instead, they use verbal sleight, but not outright lies, to persuade a patient of their competence and obtain consent.
Making patients feel comfortable and reassured is a priority. Instructors over-emphasize trainees’ skills, and trainees go along with it. They make errors, and through doing so improve for the next patient. And the cycle continues.
I understand. It makes sense. But as I enter the world of training myself, understanding why the unspoken rules are the way they are does not ease a guilty conscience.
Because at the end of the day, I find myself with two facts. One is that for serious procedures, no one would agree to be practiced upon if asked. Two is that every new doctor-in-training must learn to perform them. Being sympathetic to both sides has not helped me reconcile them.
(Certain details of this story have been modified slightly to protect the privacy of the patient.)
(Image obtained from Wikimedia Commons)