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    How to command patient trust while building experience

    Nirmish Singla, MD

    Urology Times Blogger Profile

    Dr. Singla is a urology resident at the University of Texas Southwestern, Dallas.

    “How many have you done?”

    This question is likely familiar to most surgeons. For those in training or those early in their careers still building volume, it can be an uncomfortable one to answer while trying to convince a patient to consider intervention.

    Rather than perceiving this inquiry as one intended to challenge a surgeon’s skill and expertise, however, it is worthwhile to recognize that no patient wishes to be a guinea pig. After all, our profession demands that patients entrust their lives to us and surrender their bodies to allow us to cut and intervene on them to our discretion. It is hence no surprise that patients would seek confidence in their surgeon prior to allowing them such a privilege, in much the same way a passenger on a flight trusts his or her pilot. And just as a pilot is required to reach a certain number of flying hours before he is deemed competent to fly, urologic surgeons must achieve a number of training milestones as well.

    In an academic hospital, there is a mutual expectation that trainees are to be involved in the surgical care of patients. While most patients seeking care in this setting understand this necessity—and we are, indeed, indebted to them for our training—there are inevitably those for whom this idea is unsettling. Of course, every surgeon has to start somewhere.

    More from Dr. Singla: Consider Choice E: Effective learning during residency

    In his book, “Outliers,” Malcolm Gladwell popularized the notion that mastery of any field requires 10,000 hours of practice. The challenge of residency—and undoubtedly the reason for its duration—is learning how to be competent. While obtaining a fundamental knowledge base relies heavily on independent reading (also see, , becoming adept in the operating room relies entirely on practice.

    True, there are surgical atlases to read, videos to view, and surgical simulators to use. But without directly handling tissues, finding and dissecting the right planes, appreciating aberrant anatomy, and troubleshooting unanticipated complications, one’s surgical training can never be adequate. The classic “see one, do one, teach one” mantra of mastery is perhaps a bit of an understatement when interpreted literally, but it alludes to a similar point, in that in order to master a particular procedure, one must, at the very least, feel comfortable directing a novice through it.

    Urology is a unique field in that it entails a wide breadth of surgical experience including endoscopic, laparoscopic, robotic, and open approaches. Different surgical cases are felt to have different learning curves, and there is a gradation of “level-appropriate” cases throughout training based on the perceived case complexity. The Accreditation Council for Graduate Medical Education mandates that a minimum number of cases of each type are performed in order to graduate from training, just as the pilot must surpass a specific threshold of flight hours. While the council derives these numbers based on a perception of what constitutes a reasonable learning curve, it is difficult to standardize operative competency across all trainees based on a single metric.

    Next: "Maximizing exposure to the operating room is of paramount importance"


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