Why Are We Here?

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.

2 comments on “Why Are We Here?

  1. -

    That’s a perfectly succinct and beautiful way to articulate what a good teacher is there to do, especially a teacher and educator for any health profession. I know you don’t post too often, but every time you do it’s an inspiring or uplifting or informative read, and I wanted to say thank you for that. I will remember to carry this mindset of “bringing up the bottom” for my future, regardless of what career path I land in ultimately.

    I’m wondering now… Is this the reason residents are made to go through brutal hours? They want you to be like a Navy SEAL of medicine, where you don’t bend or break under pressure, right? I think I had that idea awhile ago, but your post made it come to light again.

    • - Post author

      I think residents go through brutal hours to try to cram 10,000 hours into them in 3 years. 10,000/3 = 3,333 / 365 = 9 hours/day. Developing expertise in a short span of time is tough. Also, most places require residents just for the place to function, so they put in long hours in service to that. With regards to pressure, I suspect this comes from being an expert. At least in anesthesia, the anesthesiologist needs to be the most calm person in the room and never rattled (IMHO). I think that’s true for other specialties, too. Thanks for reading, glad it’s helpful! If you want to submit a guest post about how residencies are like Navy SEAL training, I’d love to see it, just email me!

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