Saturday, July 12, 2008

LIVE Teaching Courses: Is this "training" enough professionally?

Last weekend, the Malaysian cardiology fraternity held their annual 'live' course for interventional therapeutic procedures (MyLIVE 2008), which attracted a delegate count of some 600, with a sprinkling of foreigner participants and guest faculty mentor-proctors from Japan, Germany, Singapore, Thailand, Indonesia and India.

While some very new and innovative techniques were highlighted and showcased, this form of "show-and-tell" phenomenon has become a spectacular and well-proven success formula to teach interested doctors and allied health care workers the nuances, the practical tips and tricks of a rapidly advancing and changing field.

Percutaneous angioplasty, stenting and novel vascular imaging techniques have grown by leaps and bounds, and we are constantly renewing and refining our techniques and skills to achieve what would have been impossible or extremely dangerous to even contemplate doing, just a few short years ago.

Undoubtedly, the field of patient-friendly, pin-hole access surgical techniques has taken on a momentum of its own, and has revolutionised the way we manage our patients with structural heart or vascular disorders. Rightly or wrongly, patients have voted with their feet, and are choosing lesser invasive therapeutic or diagnostic procedures.

It's this endless catching up with rapidly morphing technology and devices, which is increasingly daunting a task for many a busy practitioner. Thus, having such teaching meetings on a regular basis can to a certain extent help meet some of the continuing professional development goals of the medical professional to hopefully expose him/her to the cutting edges of the possible.

However, many have warned that such exposition of uncommon but spectacular skills (by these experts) in very difficult and esoteric patient types and very select showcase examples might unduly influence the less experienced and undertrained doctor from going on to undertaking such interventional surgeries without adequately structured training and proctorship, thereby endangering the unsuspecting patient on the other side of the equation.

Is watching and learning by audiovisual input alone sufficient to impart adequate technical skills on such technique-intensive medical therapies? What about the touch, the feel and the finesse, that can only be learnt from repeated and mentored hands-on practice?

What then of the more rigorous mental process of doctoring, i.e. the medical diagnostic-therapeutic decision-making heuristic and synthesis--can this be taught adequately without the bias of technology-heavy influence?

Or would such demonstration courses only encourage what has derisively been labelled as "oculo-balloon-stent reflex", i.e. ballooning and stenting every possible visible coronary or vascular stenosis?

Does the internist-residency maxim of "see one, do one, teach one" apply in these sorts of scenarios? Or would these require more than such a simplistic approach? Would such exquisite skills be better perfected through painstaking apprenticeship through a series of properly supervised cases and patients, so that this training can be acceptably documented, even planned for best uptake of skills by the learning physician or surgeon?

One of the greatest criticisms arise from the fact that physician supervision in the post-specialist phase is almost nonexistent, and whichever adoption of new technologies and techniques are very much left to the honesty and audacity of the specialist concerned.

In many ways, fortune and personal gung-ho favours the brave. More importantly, they should help single out the intrinsically better physician. What is less certain is the process of sorting out the ethical concerns to ensure safety and best outcomes for the patient.

Perhaps, such courses should also educate specialists as to the technology's many unknowns and less certain practices--highlighting more clearly the potential dangers and risks of making a wrong choice or a series of missteps, and how to avoid these. But many if not all of these mushrooming 'live' courses tend to showcase the positives of superlative technical skills and expertise, rather than caution against the negatives and potential failures...

Even one aggressive interventional expert Dr Harry Suprayanata (who pioneered direct stent-angioplasty for myocardial infarction in Zwolle, Netherlands) has warned that perhaps the ultimate skill is knowing when to stop intervening, standing back and reviewing the status quo, when procedural stumbling blocks arise in spite of our best technical expertise.

I concur that we should always remember that there is a patient at the other end of our surgical or procedural reach--whose best interest must always remain our main concern. We should not be trying to succeed at all cost whatever the technical goals we had hoped to achieve, unless we are emergently saving a life...

My increasingly reinforced motto is progressively conservative--I am no longer as comfortable to accept that a technically challenging procedure was successfully performed but that the patient died or suffered an untoward consequence especially when this could have been avoided, if another course can be opted for. Whether the odds/risks are high or low matters little, if the patient comes out worse after any therapeutic intervention, than before...

Derring-do and bravado at technical skills without concern as to the final outcome for the patient is perhaps one very dangerous mindset to develop. One gets easily inured with this fixated pattern of believing in our own skills, that we get too smug with the statistics... One death or two for some is simply an accepted statistic, a number that has been found acceptable from studies, therefore we are satisfied that what we are doing is sufficiently evidenced-based!

Can a doctor be divorced from his professional pledge to heal and/or relieve pain, without adequate regard to life and the espoused practice of non-malfeasance, i.e. primum non nocere (first, do no harm)?

Does simply accepting and informing our patients that such and such a intervention/therapeutic procedure carries such and such a risk statistic or chance, suffice to absolve one's responsibility and salve one's conscience that we can then go ahead regardless?

Does trying to show-off our technical skills override all thoughts as to safety or life-threatening concerns?

Our fraternity needs to review our objectives and our purpose. We should not blindly push on just because everyone else appears to be doing it.

Let's keep our eyes right on the ball--it's our patients who are our charges, and it's our solemn duty and responsibility to ameliorate their suffering and/or to heal them as best we can and should...

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