Monday, May 21, 2007

Ones and Zeros

My preceptor keeps diligent records of my performance on his laptop computer. Spread out in sheets and boxes are the statistics of every call: IV success, percent ALS, percent BLS, airway skills, EKGs, drugs, tough calls, easy calls. The columns span to the right in seemingly endless lists, filled with binary digits designed to add objective value to my successes and failures. On secondary pages are the graphs. Pie charts lay out in colorful detail the number of times I performed certain tasks on specific patients. Lines and bars describe my hit percentage with IV sticks. My preceptor will fill in the details of each call after we finish, diligently plugging ones and zeros into the designated boxes. The graphs automatically adjust, the lines traverse up and down.

At the end of each week he prints out a report and I can see, with three digit accuracy, whether I have improved. Last week the bar graph on my IV percentage went way down. Traumas went up, along with the associated skills. A pie chart suggests that I am getting more experienced with airway maneuvers.

Still though, I wonder if he notices the things that cant be assigned ones and zeros. Looking over the report, there seems to be no value for subjective performance. No cell that captures how I remain calm and polite with the overbearing (yet uninformed) nurse, no graph describing my management and delegation of duties on scene. Nothing that makes note of how I was able to make that suicidal 9 year old laugh all the way to the hospital.

I feel like I am doing well with the things that count. I care about treating my patients well: a philosophy that I believe encompasses accurate medical care as well as comfort and compassion. I try to be mindful of those around me, politely taking reports from first responders and making requests of my help with only the urgency necessary. I know my protocols like the back of my hand, and I dont think my medicine has strayed even once from the standard of care. My first-shot IV percentage sucks, but out of almost 40 patients I can count on one hand the number of patients who I couldnt (eventually) get a line on.

I am acutely aware, though, of the things I have yet to learn. I need to get better at evaluating the whole scene, making a plan early-on, and following through. I want to get better at recognizing potential problems in advance, solving issues before they occur. (Never again will I let a patient seize on me during a 2nd floor carry down with no IV access and the Versed sealed in my pocket) I need to sharpen my ability to make the basics automatic so I can focus on the advanced. I need more time to develop a system so I can do the same thing, every time.

These are things I think about. I am my worst critic, I admit. ...But I wonder sometimes if I couldnt use a few more comments about these subjective things from another perspective. My preceptor says that I am doing fine, that his relative silence on these issues is evidence that I am performing well on my own. I am worried, though, that I am making mistakes that he doesnt see, or missing things that he does not mention.

Despite the boxes and lines, charts and graphs: I yearn for more feedback.


Blue Ridge Medic said...

I know how you feel. Thanks for the comments.


RevMedic said...

We have used paper forms for our Daily Observation Reports for years. I recently made the switch to a spreadsheet in Excell so that it looks neater.
What is the program you folks use to track this info? I am very interested. Thanks!

Shane said...

and unfortunately, that's one of the problems with the precepting process. everyone has their own criteria that they evaluate based upon. Something more important then IV success rates and such is that you're able to apply a sound thought process to the call you're in the middle of. That's much more important then anything that can have a number assigned to it. Keep your head up. you'll do fine. You just have to make it through precepting.

fiznat said...

revmedic: my preceptor is using Excel as well. The spreadsheets are of his own design, something that he has been putting together for some time now.

RevMedic said...

Thanks. We have specific criteria for the 40 different items we score. We score as Not Observed, 1 (needs work), 2 (satisfactory) & 3 (outstanding). I try to give at least a 1 & a 3 per shift, but it of course depends on the performance of my trainee. I'd be happy to share the criteria for anyone who would like it.