I was watching an interview with my favorite role-playing game GM, Brennan Lee Mulligan, and something he said made me literally sit up in my chair. I thought, “This. This is why I teach students.” And if students understood it, life would be so much easier for themselves and for me. First, though, a quick story.
I was teaching ECGs in the cardiovascular system course this semester, and got to 2nd degree AV block. One of the students asked, “I’ve heard about different types of 2nd degree AV block. Can you talk about those?” My answer: “Good question! However, that is clinically insignificant. I recommend you focus on being able to identify the arrhythmia and determine if it’s a problem.” My answer was informed by years of working with general practice veterinarians who often worried when their patient developed a 2nd degree AV block, even though everything else was fine. Here’s the deal: if you can’t even determine if a 2nd degree AV block isn’t a problem, you don’t need to waste space in your brain worrying about Type I vs Type II.
What was Mulligan’s advice? Here it is:
“I’m not here to raise your top, I’m here to lift up the bottom. … Your worst show is pretty good.”
I spend a lot of time thinking about competence, medical error, and patient safety culture, so this exchange spoke deeply to me. I’m happy when a student does a procedure quickly and expertly. I’m pleased when the residents make a tough diagnosis. But I am MUCH more interested in making sure that BAD things don’t happen regularly. Bringing up the bottom. When you’re tired, frustrated, irritated, and distracted, I still want you to be able to be a reasonably competent doctor.
This is just an extension of Aim for Zero. It’s fine to want to be an amazing clinician, but I am MUCH more impressed by students who are consistently competent. Their lows are still pretty good. During their worst case, they at least know what to do and TRY to do it. Medical error is the third leading cause of death in the US. Anything we can do to raise up the bottom improves patient care and patient outcome. Focus on bringing up the bottom, not trying to raise the top.