Medical Education: Reforming How We Train Doctors


Below, another provocative story from Pulse–voices from the heart of medicine, an online magazine of personal experience in health care.  The piece raised some questions in my mind about how we train medical students. You’ll find my comments at the end. (To join the Pulse community, and receive every issue, online, at no cost, click here.)

First, Do No Harm

By Alison Block

It's one of my earliest memories: I'm wrestling with my brother, and I'm losing, because I'm five and he's seven, and he's bigger and stronger than I am. So I bite him, hard.

Instantly I know I've crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, "He bit me! Jon bit me!" I feel shame, because I am old enough to know it is wrong to hurt people–and to lie.

Some years later, I am accepted to medical school. I go to the first ceremony of my medical career–the one where I get my short white coat–and I take a modernized version of the Hippocratic Oath. I will try to do the best I can for my patients, and I will recognize the awesome responsibility that it is to care for other human beings. I notice one thing is lacking, though–the often-quoted phrase "First, do no harm." The sentiment is there, but the words are not. I don't make too much of it.

I spend two years sitting in class learning about various -ologies, and then I take an eight-hour test, the national board exam, to prove that I've learned something. I leave the classroom, and I am finally allowed to see real patients, not just the actors in the fake clinic rooms who get paid to pretend they have thyroid disease. I ask people probing, personal questions, and I listen as they talk about their devastating diseases and lives. I try not to cry, because it feels unprofessional, and nobody wants a doctor who cries.

I ask complete strangers to undress and put on flimsy paper gowns. I touch them on their bare skin and feel embarrassed when little old ladies wince and tell me my hands are cold.

I see my first emergency room patient, a well-dressed, twenty-four-year-old man with a polite smile and fearful eyes. He complains of terrible abdominal pain that started around his belly button and has progressed to his right lower quadrant. I'm excited to examine him, certain that this is my first appendicitis. I press down on his raw, inflamed intestines, and he screams in pain–pain that I caused. I feel terrible, and unsure, but I put on my best air of confidence, because nobody wants a doctor who lacks confidence.

A few weeks later, I try to look into the infected ear canal of a fussy three-year-old, sweaty and disheveled from days of fever and discomfort. The examination hurts him, and he screams and cries so hard he can't breathe. He wiggles away before I can see anything, and I stop trying because I can't bear the thought of wrestling a small child onto the exam table.

I learn how to place IVs on plastic dummies. It seems simple and basic. I decide to try it on a real person, a genteel but anxious forty-something woman about to get her gallbladder taken out. Inexpertly grasping the needle in my visibly shaking hand, I bring it close to her fragile-appearing skin, where it suddenly looks big and sharp and scary. I poke too gently and too slowly, and it hurts her that much more. I poke deeper, at too much of an angle, and a little black-and-blue bubble starts to form under the skin around the needle.

The nurse looks at me, annoyed.

"You blew the vein," she says. "You have to take out the needle and start over."

I try three times and blow three veins. Then the nurse does it herself. Quickly, easily. I feel incompetent, and I am acutely aware that nobody wants a doctor who is not competent.

I do a trauma-surgery rotation at the county hospital, where most patients are recovering from gunshots and stab wounds. My job is to carry the wound-care bag and run ahead of the team of surgeons to undress the wounds.

I enter the first patient's room and take off her bandage, revealing a bloody, pus-stained pad of gauze underneath. I start pulling out the gauze, and much more unravels than I'd have thought possible, exposing a deep, raw, fleshy hole.

The patient shrieks. "Why are you doing this to me?" she asks, sobbing.

I want to stop, but I know that I have to keep going. I tell myself that this is all part of the healing process–that I am going to be a doctor, that my job is to heal, and that nobody wants a doctor who's afraid to rip off a bandage.

In two months I will climb onto the stage in a big auditorium to receive my robe and diploma, and I will complete the transition from medical student to medical doctor. I will sit at graduation and listen to my mentors and classmates talk about the honor and privilege of being a physician. I will know that it's true, and I will be excited. But I'll also be scared. I can tell already that this doctor thing is a lot of responsibility, and I find it hard to believe that I'm good enough for the job.

Despite my fears, though, I will stand up, and I will repeat the oath. I will be grateful for an oath that doesn't make me promise to do no harm–a promise I've come to realize that I will not be able to keep. Because it turns out that healing, more often than not, is a messy, painful, complicated process. And while I may not have known it when I signed up for this job, I now understand that, as a physician, I will need to work together with my patients through the hurt and chaos of illness in the hopes of achieving the relative calm and order of wellness.

So instead of promising to do no harm, I will promise to do my best. And I will hope that the good will outweigh the harm. Because nobody wants a doctor who does more harm than good.

About the author:

Alison Block is a graduating medical student at the University of California, San Francisco. In July she will embark on a career in family medicine. "I have always enjoyed writing about my experiences, and I began exploring writing more seriously while pursuing a research project in South India. I hope to incorporate personal essay writing into my career as a physician, as a way to continue the work of healing myself and my patients."

Story editor:
Diane Guernsey


Inevitably, doctors hurt patients.  Some treatments are painful, and occasionally, every physician makes a mistake..  

But while reading this story, I couldn’t help but wonder whether both this doctor-in-training and her patients might have been spared some of the pain, shame and trauma that she describes.

The conventional wisdom has it that doctors have to practice on someone. This may well mean “blowing” more than a few veins while learning how to insert an IV. 

But as we put more emphasis on “patient-centered” medicine, I wonder if   “watch one, do one, teach one” really makes sense.  Think about it from the patient’s perspective: you’re sick, you’re about to go into surgery, you’re afraid, and, thanks to a combination of fear and medication, you may be nauseous.  Suddenly, someone who clearly doesn’t know what he or she is doing is sticking needles into you.  The nurse is looking annoyed; the student is panicking, you feel the anxiety wash over you and your stomach tightens.

Why, I wonder, couldn’t students learning to insert IVs practice on those actors who are paid to pretend that they are patients?  Presumably, most of the actors are healthy. They’re not sick; they’re not afraid, they’re not frail. They could sign a release form. (Those who don’t like needles wouldn’t have to participate.)  The actors could be told to scream out if the procedure hurts so that the student could learn to remain calm even if the patient isn’t.   And I would suggest that students practice not just on one,  but on a dozen,  or more– however long it takes until they are are entirely comfortable with the procedure., and can do it jsut as well as a nurse.

I also think about the patient who shrieked when the gauze packing was being removed from a deep wound.  It seems pretty clear that this is a situation where pain is unavoidable. But my guess (and this is only a guess) is that a seasoned trauma nurse would be able to minimize the patients’ suffering by moving quickly–or using a technique that experience has taught her. Why ask a resident on rotation to undress the wounds? Is this part of the ‘hazing” of medical education that is supposed to "toughen them up" so that they don't mind hurting patients?  I would suggest assigning the task to veteran nurses and let residents watch while the nurse explains how the job is best done–not just once, but many times.

I also wonder what happened to the toddler with an ear-ache? Did anyone ever manage to look into her ear to see just how bad the infection was?  Again, this seems a case where perhaps the resident should have been observing while  either an ER nurse or a pediatric nurse did the examination–especially when it became apparent that the child was exhausted and terrified . Let me be clear: I don't fault the doctor telling this story. I fault the system that didn't give her the help she needed.

What I’m proposing is, first that we make better use of nurses when training medical students and residents. I realize that, today, residents do, in fact,  learn a great deal from nurses.  But I would like to formalize the relationships, making it clear to medical students, from the outset, that in many cases, nurses will be teaching them. (A long time ago, when virtually all doctors were men, and virtually all nurses were women,the notion of nurses training residents was unacceptable. Times have changed.)

Secondly, I’m suggesting that the traditional way of training doctors: “watch one, do one, teach one,” goes back to the bad old days of doctor-centered medicine when everything was organized around what might be most convenient for the physician or the hospital.  The doctor was the subject, the patient, a body part  that the physician  treated.

In an earlier era, when physicians had few cures, there was more emphasis on comforting the patient–and making him as comfortable as possible.  In many cases, empathy was all a doctor had to offer.  But in the second half of the 20th century, as modern medicine became more sophisticated, it also became colder– sometimes as cold as the glittering new technology that took center stage. Suddenly, everything seemed “curable.” The idea that medicine also is about “comfort “and “compassion” began to drop away.

In that authoritarian world, the patient was expected to do as he or she was told, making as little fuss as possible. In a profession dominaed by men, a macho code applied,–both to the physician and to the patient. A physician didn’t wince if a patient screamed; he remained silent and impassive. (Never say you’re sorry. Someone might sue you. ) And, of course, a “good” patient didn’t shriek. She dug her nails into the palm of her hand.

But as Harvard pediatrician and CMS director Don Berwick suggests in an essay on patient-centered medicine, health care reform requires rethinking how we train medical professionals:   “We will not teach future professionals emotional distancing as a strategy for personal survival,” he writes.” We will teach them instead how to stay close to emotions that can generate energy for institutional change, which might help everyone survive.”  For more on his essay, scroll down to “The Heart of Patient-Centered Medicine” in this HealthBeat post.

 The author of “First, Do No Harm,” is clearly sensitive to what her patients’ feel. I would add only one line to this fine story: “No one wants a doctor who never says, ‘I’m sorry, I know that hurt.’”

29 thoughts on “Medical Education: Reforming How We Train Doctors

  1. “What I’m proposing is, first that we make better use of nurses when training medical students and residents”
    Applause! Medical students can learn a lot from trained nurses on basic bedside skills.
    However, not all nurses make the greatest of teachers. We nurses often eat our own young. The training of medical students will have to become a part of the culture for both nurses and physicians . . . but the payoff would be a greater understand and respect from one to the other for the jobs that they do.
    “Why, I wonder, couldn’t students learning to insert IVs practice on those actors who are paid to pretend that they are patients?”
    Or how about this: why don’t they practice on each other? That’s how I learned to both give injections and start IVs. Sadly, we’ve moved away from this useful teaching tool for both physicians and nurses . . . schools worry about liability if a mistake is made and a student is injured.
    ““No one wants a doctor who never says, ‘I’m sorry, I know that hurt.’””
    Great point. I would much rather have a doctor who is a good human being than one that strives for a perfection none can attain.

  2. Pancea–
    Thanks much for the input.
    Yes, I can well imagine that not all nurses make great teachers.
    I would suggest that both head nurses and attendings (and perhaps 3rd year residents) should nominate nurses to become mentors who demonstrate skills at the bedside
    My guess is that nurses who were chosen would appreciate the reocgnition, and be more than happy to do this–. Tather than having to stand by passively, while a resident hurts a patient, they could help both the patient and the resident.
    It didn’t occur to me that, of course, residents and med students could practice inserting IVs on each other. The liabilty argument strikes me as something invented by hospital lawyers. (Many corporate lawyers spend their time dreaming up reasons why “we can’t do this.” They are justifying their salaries, but not really protecting the corporation.)
    What med student is going to sue his school unless it did something truly wrong? (Suing would pretty much end his or her career.)
    Of course, students should have the option of saying: “I don’t want fellow students practicing on me and I don’t want to practice on them.”
    Under the law, if this is voluntary, it should cover liability.
    And yes, I think most of us would prefer a doctor who is capable of empathy–and apology.
    As I’ve written in the past, research shows that doctors who are able to say “I’m sorry”–and explain what went wrong–are much less likely to be sued for malpractice.

  3. Maggie- Thanks to you and Dr. Alison Block.
    Doctors need a HUGE dose of humility which is all but completely obliterated bt current physician training methods.
    Not only do we have to say “I’m sorry that I hurt you” much more often we also need to say “I don’t know” (the latter statement requires more patient maturity as well)
    Dr. Rick Lippin

  4. Hi Maggie,
    Thank you so much for your insights and comments on my essay, “First, Do No Harm.” I think that you are absolutely right that in many regards, aspects of medical training need to be re-thought — better interdisciplinary, collaborative relationships with other healthcare providers such as the nurses and medical assistants, a more patient-centered approach, etc.
    However, as you mentioned, many times, the pain inflicted by medical professionals on patients is unavoidable. With the 3-year-old with the ear infection, for example, an ear exam is extremely uncomfortable no matter who is performing the examination. For cases like this, I feel that the main change that needs to be made in medical education is preparing future doctors for the reality that they sometimes will cause pain for their patients. We need to work on minimizing this pain as much as possible, of course, but also preparing learners to handle these experiences appropriately so that they don’t, as you suggest, let their anxiety increase the anxiety of their patients.
    Once we acknowledge that healthcare providers often “do harm” to patients, then we can learn how best to help and comfort patients (and medical students) through this experience. Like by saying “I’m sorry, I know that hurt.”
    Thanks again for reading and for your comments!

  5. As a physician, I think there’s some things I need to correct about this article.
    1. Nurses arent trained or qualified to diagnose ear infections (unless you are talking about NPs). Although an experienced pediatrics nurse probably could help find a better way to comfort the child and hold him still during the exam, the nurse wouldnt know how to interpret what he/she sees in the ear canal. To accurately diagnose an ear infection you need a resident/attending to look at it. Neither a fresh med student nor a pediatrics nurse with 25 years of experience is qualified. I’ve worked in a childrens hospital for 10 years now as well as a pediatrics clinic and I’ve NEVER seen a nurse look into a child’s ear with an otoscope. That’s a physician/NP scope of practice.
    2. You keep referring to “residents” in your post while citing the example of a med student. Residents are very, very different than med students. Although a resident is still learning, he/she is several-fold more competent than a med student fresh on a pediatrics rotation. They are entirely different animals.
    3. The average doctor will never be as good as the average nurse at getting IVs, unless you are talking about special lines such as central lines, arterial lines, etc. Nurses place IVs every single day; doctors may place an IV once a week perhaps. 25 years ago doctors did most of the IVs, but there are so many patients that need them now that doctors put that onto the nurses because otherwise they wouldnt be able to see other patients because of drowning in IV requests. To be good at IVs requires dozens and dozens of attempts. Just attempting 3-4 on a “practice patient” or a med student classmate wont cut it. Since nurses end up doing 99% of IVs in clinical settings anyway, I’m not sure that med schools should go out of their way to train med students on how to do IVs since they wont be doing them during clinical practice anyway. There are bigger fish to fry.
    4. Good luck asking the nurses to undress every trauma wound before the doctors walk in. The docs would love it, it would make bedside rounds a lot faster if all the wounds were unpacked by nurses before the docs came in the room. Most of the nurses I know would balk at that. They’re busy doing other stuff. The average resident is extremely competent at undressing wounds; so I wouldnt lump them in with med students. The reason med students are asked to undress trauma wounds is to speed up rounds; if nurses were willing to do it then trust me the trauma surgeons wouldnt be asking med students to do it.

  6. Another comment: Maggie’s article is based on the notion that inexperienced people should not be doing very much to real patients.
    While it may sound like a nice idea, its totally unworkable in reality.
    Forget about doctors for a second. How are the NURSES going to learn these things if only nurses with 10 years of experience are allowed to do them?
    I work in a large childrens hospital and we dont have enough of those
    “experienced” nurses to do everything like Maggie wants.
    Maggie’s article presupposes that when you walk onto a pediatrics ward at a hospital that you’ve literally got legions of experienced nurses willing to help out “inexperienced” doctors. But thats simply not the case. On a typical ward of 25 patients, there might be 1-2 very experienced nurses there along with a slew of newer nurses who havent been there that long. The 1-2 very experienced nurses dont have the time to do all the procedures for the 25 patients on the floor. They’re busy doing other stuff.
    The reality is that there are tons of “learners” in the hospital at any one time and only a few of them are doctors. The notion that the hospital is full of “experienced” nurses and “inexperienced” doctors is not true. There are many inexperienced people on both sides.

  7. One truism about ear exams — most toddlers scream when you do them, regardless of whether they have a real ear infection or not.
    Its an absolute myth that if a toddler screams during your exam that you must be hurting them or that they have a very sensitive ear.
    I’ve probably looked at 5000 different sets of toddler ears, and its rare when the child doesnt get upset; even for ears that are not infected. Bottom line is that its usually not due to pain, its the fact that toddlers just dont like people holding them still to look in their ears and the only way they have of communicating that is to scream.
    We always have the parents hold the child in their lab, facing sideways, and have the parent hold the child’s head sideways against the parents chest while locking their legs and holding their arms still so that we can get a good look a the tympanic membrane. I always tell my med students that they should save the ear exam for the last part of the physical exam (since its usually the most invasive) and to ALWAYS have the parents hold them in that fashion because it makes the exam a lot faster and easier that way for everybody and makes the diagnosis a lot more accurate.

  8. Dr Lippin: “Not only do we have to say “I’m sorry that I hurt you” much more often we also need to say “I don’t know” (the latter statement requires more patient maturity as well)”
    I couldn’t agree more. Nurses need to be able to say the same thing. Sometimes the public has an unrealistic expectation of what nurses should actually know . . . and I’ve heard many colleagues try to BS their way out of admitting they don’t know something.
    I encourage my nursing students to say, “I don’t know . . . but I will find out.” I have never had a patient get upset for admitting a lack of knowledge as long as I research an answer.
    Jackie: “Nurses arent trained or qualified to diagnose ear infections (unless you are talking about NPs).”
    Let’s get real a minute, here. You’d be surprised at what an RN knows. I’m not an NP . . . but I took a 16 week course in physical assessment, including the use of an otoscope. I can look in an ear and know what otitis media looks like, as well as make a determination based on other findings (fever, loss of appitite, pulling at ears, fussiness).
    Legally, nurses don’t diagnose. Practically, we do it all the time . . . that’s the dirty little secret of medicine.
    What nurses lack is in depth training in differential diagnosis. Common problems are easily recognized by the nurse with little effort, and I am often asked for my input on diagnosis by physicians who trust my judgment. However, I and all nurses I know recognize there are nuances to diagnosis we lack that would cause us to miss certain conditions, particularly rare ones. And diagnosis, quite frankly, is not our role.
    But please don’t underestimate what we can do.
    As to your comments re residents vs med students. While I agree in principle, in practice I think we need greater recognition that residents are in fact, still students. If they weren’t, attendings and senior residents wouldn’t have to approve everything new residents do. Residents are very much beginners, with loads left to learn, and need considerable supervision. We should start treating them as the students they are . . . it would reduce the rate of preventable errors they make.
    Re your comment on IVs. I do agree that most doctors will never be as good as the nurse who does IVs all the time. Most nurses aren’t as good as the nurse who starts IVs all the time: IV therapy nurses, ER nurses, ICU nurses, OR nurses, and other critical care specialties. However, in a crisis, when the nurse can’t get the IV, she often turns to the doctor to do it. So doctor’s should acquire and maintain competency in this basic skill.
    It takes 3-4 successful sticks to acquire basic competency. It takes dozens to achieve mastery. IV starts are common enough that residents can reasonably be expected to achieve mastery of this skill, and it’s like riding a bike . . . you never forget. I seldom start IVs anymore now that I am teaching . . . but when I do, I find I have no difficulties.
    I also agree with your commment on unpacking wounds . . . nursing staff are far too busy to do this, and in many cases surgeons want to do the first dressing change of a surgical wound. The change needs to come in that the residents/med student is given sufficient time to unpack the wound . . .that they don’t do it in a hurry. And nurses could certainly teach med students how to do it correctly as not to hurt the patient.
    I don’t think Maggie means inexperienced people should not be allowed to do things. I think she means they should get sufficient supervision and mentoring to help them learn how to do things quickly.
    We have this culture in nursing of “if you want it done right, do it yourself,” so many experienced nurses don’t want to take the time mentoring new staff so they learn these skills adequately. We have to accept that we simply can’t teach everything in nursing school any more. There’s just too much to squeeze it into a two year curriculum anymore (and let’s face facts, even in a BSN program it’s still a 2 year curriculum–the first two are spent on gen eds). Which is why I like Maggie’s suggeston of nursing residencies. New grads should spend time in a specialized training program similar to medical residencies to help them adjust from the 1-3 patients a student cares for to the total care of a team of 6-10 patients most med surg nurses care for.
    One hospital in my area does something like this in their GNOSIS program: new grads spend time in the classroom learning nursing policies and procedures, refining skills like IVs, then rotating through the hospital working with a mentor for 12 weeks before they ever begin work on their assigned units.
    Jackie makes good points about the ear exam, and that’s the way I do them in the ER. I also find, however, that some people are just better with building trust with toddlers than others. I know a great ER doc who can perform an ear exam with nary a cry of protest . . . because he’s just that good with kids in general. Some people got it . . . some don’t.

  9. Jackie–
    First, let me say that your statement that toddlers almost always scream during an ear exam just isn’t true.
    As a mother of two, one of whom had frequent ear-aches, I never heard her scream.
    And I never had a pediatrician (or other doctor) suggest that I pin my child down, so that she can move neither her arms nor her legs while the doctor examines her.
    One doesn’t need a medical education to know that this would panic a toddler (or anyone) who is already in pain.
    As Panacea notes:
    ” some people are just better with building trust with toddlers than others.”
    As Panacea also points out, many nurses can recognize an ear infection when they see it and have been trained to use the instrument needed to do the examination.
    Your attitude about heirarchies within the medical profession(residents and interns are entirely different animals, etc.) are rigidly old-fashioned..
    As Panacea also notes residents and interns exist on a continuum — a learning curve.
    Unfortunately, residents who are not adquately supervised are responsible for a great many medical errors. I have written about this before. And because they work such long shifts (and often are forced to work illegally long shifts) they often make mistake because they are tired.
    Residents have much to learn from experienced nurses.
    As for the notion that doctors have “bigger fish to fry” than learning how to do IVs without hurting patients . .. you admit you do them once week.
    I guess you think that once a week a patient should suffer because you have “bigger fish to fry” and don’t have time to maintain your competence in inserving IVs?
    Again, as Panacea points out, doctors should make sure that they keep their hand in and are as able as an experienced nurse to insert an IV without causing unneceessary pain.
    I’m not suggesting doctors learn by practicing on each other “2 or 3 times”. I’m suggesting that they learn by practiciing on each other for as long as it takes to be able to do it without hurting hte patieint.
    Med students and residents tell me that because medical education hasn’t changed in years, they spend much time learning things that are not useful in clinical practice, too little time learning things that would be useful in practice.
    On undressing wounds: in the story Alison is asked to undress a wound for the very first time without supervision.
    This is simply wrong. No patient who is already in that much pain should be used as a “practice doll.”
    And no novice should be p put in the postion of trying to undress a deep wound by herself.
    On inexperienced people touching patients:
    As Panacea understood I am not saying that 10 years experience is needed before touching a patient, but that both new nurses and residents should be mentored and supervised whenever attempting a new procedure. And “watching one” once is usually not enough.
    You suggest that nurses are too busy doing “stuff” to take the time to make sure that patients are not hurt.
    Research shows that there is much inefficiency in most U.S. hospitals with people running around “doing stuff” without thinking. This leads to overtreatment, overtesting, redundancy adn errors.
    We need better systems. Doctors and nurses need better systems to learn to do their job efficiently and in a way that is patient-centered.
    The patient comes first.
    I would suggest that you go on the website for the Insitute for HealthCare Improvement and consider attending their conferences.You might learn something about collaboration, teamwork and patient-centered medicine.

  10. In Jackie’s defense, I would say I don’t think Jackie meant to suggest pinning a child down for an ear exam. It is, however, important to keep the child’s head still because if the child moves (and the ear is often sensitive if an infection is present) you can accidentally cause an injury with an otoscope.
    Toddlers usually respond well to being held loosely by the parent in their lap.
    I never have to pin a toddler down for anything. Toddlers are surprisingly able to understand simple explanations using simply words. I find that taking the time to speak directly to the child, using simple terms but not talking down to them, does more to acquire their cooperation than wrapping them in a sheet or using a papoose board. I let them see and touch the equipment. I give them permission to be afraid and permission to cry if they hurt . . . all I ask is they not move.
    And they can do it: they’ll cry, but they’ll hold still so I can get the job done quickly.
    The time it takes to do it that way is no more than the time it takes to force a terrified, struggling child to hold still.
    Like you said, Maggie, it all goes back to being patient centered 😀

  11. “I never have to pin a toddler down for anything.”
    You dont do IVs on kids? Please dont tell me you can talk them down for that one too.

  12. “First, let me say that your statement that toddlers almost always scream during an ear exam just isn’t true.
    As a mother of two, one of whom had frequent ear-aches, I never heard her scream.”
    I’ll put my experience up against yours any day of the week. Your sample N = 2, my sample N > 5000.
    Yes, there are some toddler age kids who do totally fine w/ ear exams, but MOST of them will squirm, kick, or cry unless you use some tricks to calm them down. Sometimes those tricks dont work and they will scream thru the exam. Kids develop “stranger anxiety” after 6 months of age and even if their ears feel totally fine they will often resist a stranger coming in close proximity to stick a tube in their ears.
    My point is that stranger anxiety has just as much to do with upset kids during ear exams as otalgia does; so its ridiculous to assert that every kid who screams during an ear exam does so because the examiner is hurting them and/or doing the exam improperly, which is what your original post suggests.

  13. Jackie said, “You dont do IVs on kids? Please dont tell me you can talk them down for that one too.”
    Absolutely I do! Do it all the time, or did when I was still working in the ER regularly.
    When I first started as an ER nurse, I fell for the “strap ’em down” approach . . . and loathed the results. The kids were terrified as well as sick. I believed I was being cruel, with the best of intentions.
    Then a colleague showed me how it can be done without torture. And it WORKS. A calm demeanor, speaking to the child in terms they understand, let them touch the equipment, make no promises you can’t keep, and give them permission to cry.
    I tell them, “as long as you don’t move the arm I’m working on, you can cry as loud as you want, you can even kick your legs. Just don’t move your arm.”
    Toddlers aren’t stupid . . . they get it. They’ll kick, they’ll scream . . . but they won’t move that arm.
    Bear in mind . . . they know they’re sick and they just want to go home. I play to that . . . make it clear this is how they get home.
    And often, the tears and the crying is less than if I strapped them down . . . more of a way of telling themselves they have control even though they know they don’t.
    It’s easier on the parents, too. They are much more likely to support me if they believe I am trying to make the process less painful. . . turns the protective instinct down and makes them my partner not my adversary.

  14. Panacea & Jackie–
    When my daughter was almost 3 , she was jumping up and down on the sofa, just before bedtime,
    and split her lip, very badly, by hitting the hard arm of the sofa.
    The bleeding just wouldn’t stop , and so I wound up taking her to the ER.
    There, the doctor stopped the bleeeding, but said that if he didn’t stitch the cut, she would probably wind up with a small scar.
    But stitching it would require putting her head in a vice so that she didn’t move.
    I asked if I could just hold her rather than putting her head in a vice. He shook his head, sadly, “She can’t move even slightly.”
    He explained that it was up to me.
    After talking to him, I decided I would much rather risk a tiny scar rather than the trauma of having her head put in a vice.
    He seemed to agree–or at least had no problem with my decision.
    This was about 25 years ago. I would describe this young doctor as a patient-centered physician who believed in shared decision-making well ahead of his time.
    Emily (who is quite beautiful) wound up with a very tiny white scar on the edge of her lip–barely noticeable a few years later, virtually invisible now.
    As for ear exams, it strikes me that in a chldrens’ hospital there are likely to be enough docs and nurses who can look into a chid’s ear–or do an IV– without “strapping them down” to designate them to do these procedures.
    As a parent, I would rather wait an extra 30 minutes for that person to become available.
    And I continue to think that, when training docs and nurses–especially those who plan to go into pediatrics–teaching them how to do procedures without “strapping them down” should be a top priority, even if it takes time.

  15. In many fields and professions there is a certain amount of just “throwing” a new person into it, and making them learn quickly through a trial by fire. Anytime there is a lot to learn, it is hard to completely avoid this method. However, in the case of medical professionals, there should definitely be more of an effort to avoid this, since the patients are forced to go through the doctor’s trial by fire with them. Probably one of the best untapped resources, is taking advantage of the wealth of knowledge most nurses have, and creating a formalized structure where nurses pass along their experience and real-life knowledge to doctors.

  16. I agree there are often times an exam can be done in the parents lap and that often makes an exam easy. I would put forth that “First do no harm” means doing a good exam so nothing is missed, which means in the case of an ear exam not compromising the exam. Obviously starting with the benign techniques and if you can complete it great, but bottomline is the exam needs to be completed. Can any of us seriously remember being traumatized by an otoscope in our youth? I use the papoose for some finger/nailbed injuries. If we are truly talking about doing no harm, it risk free to fully sedate a 3 year old for something that could have been done in a papoose? Anesthetic complications happen. People die from them. Some fractures can be reduced while putting on a cast. There can be 5 seconds of a sharp pain and it’s done or an IV start with an anesthetic and all of the risks associated with that.

  17. JR: It’s only fair actually, when I consider how much I learned from doctors.
    Jenga: When it comes to conscious sedation, I can see where you’re coming from.
    But I used to know a doc who would refuse to use a local when putting in staples. His rationale was the patient would feel pain anyway. I didn’t agree: the type and quality of pain matters. I’d rather get numb first.

  18. There is a place for it confining a kid to a papoose. It sucks to have to use it, but there is a place. To take Maggie’s example farther, what if the choice is big scar, papoose or surgery. The papoose may balance risk and outcome the best of all.

  19. Peter writes: When you die Maggie they should put ‘research shows’ on your headstone.
    Joe Says: I coughed up my pepsi laughing when I read that one Peter. I would respectfully add that if you could say the same in 1000 words, it might be more fitting, 😉
    Love ya Maggie!

  20. Absolutely I do! Do it all the time, or did when I was still working in the ER regularly.
    When I first started as an ER nurse, I fell for the “strap ’em down” approach . . . and loathed the results. The kids were terrified as well as sick. I believed I was being cruel, with the best of intentions.
    Then a colleague showed me how it can be done without torture. And it WORKS. A calm demeanor, speaking to the child in terms they understand, let them touch the equipment, make no promises you can’t keep, and give them permission to cry.
    I tell them, “as long as you don’t move the arm I’m working on, you can cry as loud as you want, you can even kick your legs. Just don’t move your arm.”
    Toddlers aren’t stupid . . . they get it. They’ll kick, they’ll scream . . . but they won’t move that arm.
    I get the impression we are talking about 2 different things. I agree you dont have to papoose every single one of them, but there’s no freaking way a 15 month old is just going to keep his arm still while you put a needle in it, not unless they are terribly ill/lethargic and have altered mental status.
    At a minimum you’re going to need somebody to hold that arm still.

  21. Probably one of the best untapped resources, is taking advantage of the wealth of knowledge most nurses have, and creating a formalized structure where nurses pass along their experience and real-life knowledge to doctors.
    I still think you are vastly overestimating the experience level of nurses vs doctors.
    As I said, in my hospital each pediatric ward has 20-25 rooms, with about 10-12 nurses taking care of those patients. Out of those 10-12 nurses, at any one time I’d guess there’s only 2 or 3 nurses maximum who I’d consider “experienced.” The rest of them are just as fresh as the doctors in training.
    So where are you going to get this huge cadre of experienced nurses to take all the “young doctors” under their wing?
    I know there’s a lot of people on this board who like to think that every patient has a grizzled veteran nurse of 20 years experience taking care of them, but thats just not the case. Those kind of nurses are rare.

  22. Jenga,Susan,Jackie
    Jenga- I agree that the
    ear exam must be done.That is what I worried about when reading the story– did anyone ever manage to look into the child’s ear?
    I also agree that very young children should not be sedated unless absolutely necessary.
    But, as you say, often an exam can be done in the parent’s lap, without screaming.
    I realize that this is not always true. Sometimes, the child may be very anxious, often, because the parent is anxious– or because the doctor isn’t very good at dealing with toddlers, and so the doc is anxious.
    But it would seem to me that all pediatricians, as well as ER docs who wind up seeing many kids with ear aches etc., would want to learn how to make toddlers comfortable. If there is someone in their ER, hospital or practice group who is very good at this (either a nurse or a doctor) I would think the doc would seek out this person to learn how to do this.
    Learning how to calm a child is like learning how to calm an excitable puppy – you don’t have to be a dog whisperer, you just have to care.
    Thanks for the link. And yes, patients should ask questions!
    When my children were 15 months old, I could calm them down enough to keep an arm still simply by nursing them–or in Emily’s case, just by giving her her pacifier. (She was like “Maggie” in The Simpson’s.)
    If a doctor works with the parent,and the parent is relatively calm, my guess is that in a great many cases, the doc and parent could make the whole procedure fairly simple.

  23. Jackie said, “I get the impression we are talking about 2 different things. I agree you dont have to papoose every single one of them, but there’s no freaking way a 15 month old is just going to keep his arm still”
    While I’ve used the technique I’ve mentioned on kids as young as 18 months, you are right . . . typically that age is too young. And even with older toddlers (up to 3 or so) the parent still plays a role.
    Usually when I say “toddler” I mean kids between the age of 2-4 years old. With that age group, it works great. Younger than that, and definately infants, sure . . . you need help. But I still use good therapeutic techniques (voice, touch, and body language) to establish what trust I can before I get started.
    Regarding your comments re “experienced” nurses . . . well, it really does depend on what you’re asking them to teach a med student or resident, doesn’t it?
    My first two years on the job, I was pretty green, sure. But a nurse with at least that much experience ought to be experienced enough to teach basic skills she performs on a daily basis to a med student.
    I was competent putting in a foley, or doing a sterile dressing change without breaking sterile technique even when I started my first job . . . and that was when I was an LPN. Sure, as a first year nurse I wouldn’t have wanted to teach med students anything. I would have been too intimidated.
    But by my second year of practice, I was an old pro as these skills . . . because I did them so often. I didn’t give a second thought to helping out nursing students or new hires who had questions.
    I think a nurse who has just a couple of years of experience is perfectly competent to teach the basics to a med student or resident. She should be completely competent at these skills by this point. Skills performance is EASY . . . what’s hard about nursing is the critical thinking component.
    I don’t think you give the nurses you work with enough credit.

  24. A have been a family doc for 22 years. Listen to me, not to the non-doc that don’t know jack about what you will go through.A blown vein? Whining about a blown vein? Just wait until the first time you kill someone. And it will happen.
    Get tough, Alison, or you’re not going to hack it. You have elected to stand for the next 40 or so years in the fire of human suffering. You have a chance to do a hell of a lot good, and that makes it worth it. Be strong. Read “The Greatest Benefit to Mankind” by Roy Porter. It will tell you what you have decided to become and will inspire you.
    You have elected to separate yourself from the rest of humanity. Other foolish posters here may scream foul, but listen to me, not them. I live this daily, and I like it a lot. Be strong.

  25. jsmith–
    Responding to Alison, you write: “You have elected to separate yourself from the rest of humanity.”
    It’s quite clear that you have succeeded in attaining that goal.

  26. Mahar you just don’t get it. Never have, never will. Have fun in your echo chamber.