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Tuesday Apr 30, 2019

It's Humbling to Be Reminded How Much There Is to Know

I recently misdosed an antibiotic for an elderly patient with chronic kidney disease.

[keep learning on billboard]

Within a few days, my patient's infection had improved, and she recovered without any noticeable consequences from my error. Regardless, my miscalculation brought to the surface questions that have been lingering in the back of my mind lately: Have I lost the edge I had when I left residency armed with the most up-to-date evidence and a wide array of experience covering the broad spectrum of family medicine? Has my post-residency career somehow weakened my knowledge base from where I was six years ago?

I know that the logical answer is no. In the six years since I completed residency, I have continued to learn from my patients, from the conferences I have attended and from the multitude of resources I use to look things up throughout each day. The sheer number of patients I have cared for in practice is exponentially higher than the number of patients I saw in residency, and although volume of patients does not absolutely equate to good and appropriate care, the experience has given me a deeper level of confidence in my ability to distinguish normal from abnormal and sick from not sick. Over the years, I have been able to hone my procedural skills, as well.

Furthermore, I have grown as a physician in subtle, less measurable ways. I am able to approach patient care with a better understanding of the art of medicine, accepting what medicine can and, sometimes, cannot do for our patients. Additionally, I have matured in my role as a supervising physician, managing advanced practice clinicians and support staff, teaching our newer staff how to provide team-based care, and addressing the challenges of providing evidence-based care within a patient-centered medical home.

Family medicine is a fascinating, challenging and ever-changing field. The range and diversity of conditions that walk through our doors is part of why many of us chose this specialty. As family physicians, we also work with our patients as they navigate the health care system, we bear witness to their social determinants of health and we acknowledge the complexities of family dynamics, often caring for multiple members of one family through a range of life stages.

Many of us choose to advocate for our patients at local, state and national levels, a skill that is just as important as those we bring to the exam room. Family medicine is broad, and the areas of focus that we choose to excel in may ultimately leave us less comfortable in others.

In residency, a finite period of time, we often sacrificed many aspects of our lives in order to gain as much experience as possible in as many areas as our programs had to offer. After residency, we strive for a more appropriate work-life balance, recognizing that it is not a constant and that our needs will change throughout our career and life. I feel fortunate that I truly love my current job and am satisfied with the balance I have struck for the time being. As a mom, wife and daughter, a variety of life circumstances have required me to focus on the "life" part of that balance recently.

As I processed my concerns after the misdosed patient, I realized that it is healthy to have periods in our careers when we question our abilities and knowledge as physicians. These moments motivate us to be better, learn more and expand in new ways. It is humbling to remember how much there is to know.

Working purely in an outpatient setting for the past few years, I am aware that I have forgotten some of the hospital medicine I once knew, and I am sure some other knowledge I have retained is outdated. I miss the regular journal clubs, grand rounds and change of rotations through different specialties. Had I continued with my first position postresidency, I would still be working with residents and in the hospital, and I would therefore still be exposed to many of the structured learning and formal educational moments that infuse residency programs.

However, I am also now more cognizant of the many ways I am still learning within my current position and that it requires a more proactive approach to learning. For example, I used to set aside time each week to read one article or glance through the latest AAFP journal. It is only because of my error and the ensuing reflection period that I realized I had stopped doing this, and the effect it had on me was to make me question my abilities.

I am making time again for my weekly CME reads and realizing that the moments when I look things up during the day are also ways in which I am continuing to learn. With a few conferences coming up, I am looking forward to additional structured learning opportunities.

So where does that leave me?

A patient called me recently because her husband, who is also my patient and has end-stage colorectal cancer, was in severe pain. He has chosen to forgo standard treatment and was in hospice care until last month, when his insurance lapsed. The wife contacted my office because they couldn't afford to pay out of pocket to have hospice come to the house, and they didn't know where else to turn. Although it had been several years since I dosed morphine for a patient dying from cancer, I didn't hesitate to offer this for my patient. I knew what resources to use to ensure I was prescribing correctly, and I knew what to tell the wife about side effects and possible risks. Moreover, I knew how to have the conversation about administering pain medications to her dying husband.

I knew the right thing to do for my patient, and I was confident that I could do it.

Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services at community health centers in the San Francisco Bay Area, with a focus on providing evidenced-based care for underserved communities.

Read other Fresh Perspectives posts by this blogger.

Posted at 04:09PM Apr 30, 2019 by Margaux Lazarin, D.O., M.P.H.

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