August 18th, 2010

Nay Fellow Way?

CardioExchange welcomes this guest post, reprinted with permission, from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem, Evanston, IL and a Clinical Associate Professor of Medicine at University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.

It was to be a routine pacemaker.

The parties assembled. The room prepped. IV started. Chest scrubbed. Antibiotics given. His nervous eyes raised when he saw me before the procedure, relieved at the sight of at least one familiar face.

“Are you ready?” I asked.

“Yes,” he replied, “I think so.”

“Any last minute questions?”

“I don’t think so,” he said.

“Great! Then let’s get this over with…” I turned to the lab staff and signaled them to proceed.

“Oh, doc! I forgot. Can I speak with you a second? Ya know, privately?”

“Sure,” I said returning gurney-side. I drew the curtain.

He leaned forward and whispered: “Doc, no fellow, right?”

I stopped and contemplated the question, then acquiesced. “Would you mind if I use one as my scrub tech, but I’ll be the primary operator?” I asked.

“Yeah, that would be okay – as long as you’re the primary operator.”

* * *

This little exchange got me thinking: what would I want? Honestly, I’d probably want an attending physician working on me, too. After all, it makes sense, right? Get the most experienced hands and all.

But there are good reasons to have a fellow involved with your surgery, if the opportunity presents itself:

  • We need to keep training. None of us will be doctors forever, and now more than ever with tons of people entering the healthcare marketplace there is a need to have well-trained doctors in place to meet the need ahead. You can read all you want about how to do a procedure, but until you’ve done one yourself on a living, breathing individual, you have no concept of the complexities involved. Starting slow in a closely supervised, supportive setting makes for some very technically-savvy doctors of tomorrow.
  • They improve your surgical technique. The better I can teach someone to do what I do, it seems the easier it is for me to do it, too. Throughout our careers as doctors, we work hard to solidify our competency “brand” amongst our patients and peers. Particularly for specialists: screw up a case or two and your “brand” is quickly tarnished. This is especially important as we train fellows – none of us wants to tarnish our “brand” when trainees work with us either. Therefore, you better bet that bottom dollar we’ll be supervising those fellows closely.
  • Fellows keep you sharp. Oh sure, they often ask mundane questions, but occasionally they ask remarkably astute questions, too. When this happens, they make us think and as a result, we all get smarter.
  • They’re another set of eyes and hands. It never hurts to have another set of eyes contribute their interpretation to a tough case or an extra set of hands for that extra retractor. Ever.
  • They slow you down. There is no question that teaching someone else takes more time than doing a procedure yourself. This definitely has its downside. But time spent now might pay large dividends in the future when that same doctor has to work on you someday. Also, spending a bit more time can have its upsides — especially if you really don’t want to have dinner with your mother-in-law.
  • More often than not, fellows are extra-careful. By their very inexperience and their desire to excel in training, I have found most fellows I work with especially conscientious when they are dealing with patients and their procedures.

So the next time you have surgery and are introduced to a training fellow in medicine, consider letting a fellow help out on your procedure.

It might just be the best thing you ever did.

One Response to “Nay Fellow Way?”

  1. I find that having fellows is mostly positive. I learn from their questions, and it makes me keep up with the literature so that I can adequately answer their questions.

    There is no doubt, however, that it is nerve racking when the fellow is getting vascular access in a way that is different from mine, or when they are twirling catheters in the aorta or wires in the coronaries in a way that I would not.

    Often times the fellow has worked up the patient before they are entering the lab, and so the patient often recognizes the fellow when they enter the lab.

    When a patient requests that no trainee be present, I explain that cath is a two person procedure, and I need the extra hands. I also explain that the benefit of being in a teaching hospital is that there are many physicians reviewing your case repeatedly, which makes it more likely that information doesn’t fall through the cracks. In a procedure, the benefit is that the attending takes their time and doesn’t rush. Most times, the patient is satisfied with these explanations.

    I am also generous with my sedation, so that patients don’t hear or don’t remember, the teaching points of the conversation (don’t push that wire!).


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