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Teaching and Learning Moments

From Reflex to Reflection: A Resident’s Perspective on Learning in a Clinical Setting

Patel, Veena MD; Stewart, Diana MD, MBA

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doi: 10.1097/ACM.0000000000001744
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As an intern on the inpatient medicine wards, I quickly learned that my responsibilities entailed, but were not limited to, writing notes, answering pages, and placing orders. These tasks were tangible; if I completed them, I was doing my job well. I was told on the first day of my first wards month to ensure that each patient had routine labs ordered for the next morning. So I made sure I did just that. No questions asked. Ordering routine labs quickly became a reflex for me, another box on my to-do list that simply needed to be checked off. If I forgot, a cold chill would shoot down my spine and I would frantically beg the nurses to draw the labs before anyone noticed.

During a busy inpatient rotation, I cared for Mr. Smith, a middle-aged gentleman admitted for pain control from metastatic cancer. He had been through a lot, but you would never know it, as he was always pleasant and cheerful. One morning, his nurse informed me that he had refused to have his labs drawn; the night nurse had tried unsuccessfully for 30 minutes. A patient without morning labs!? I could feel the cold chill start down my spine as I scurried over to Mr. Smith’s room to convince him to have his labs drawn. When I entered his room, I didn’t see the cheerful Mr. Smith. He had multiple bruises on his arms and was on the verge of tears. His exhaustion was palpable. “I really can’t take this anymore; can I please just rest?” he pleaded.

After seeing his distress, I reflected on the utility of his daily labs. I reviewed his chart and discovered that, since admission, the results of all of his labs had been normal. He had spent seven days in the hospital for pain control, and I had ordered a complete blood count and basic metabolic panel each day. The results of these daily labs never changed his inpatient management. Why did I not catch this? Why didn’t my attending or team comment? How many other patients were getting stuck each day due to my reflex ordering?

Mr. Smith made me take a step back and think about how I was practicing medicine. Ordering labs was not just a checkbox—it was an ordeal for my patients and a wasteful, costly practice. From speaking with my fellow residents, it was clear that everyone was guilty of unnecessary ordering. If we all knew it was unnecessary, why did we keep doing it?

I was inspired to take action. With the help of faculty trained in quality improvement, I led a project to decrease unnecessary lab draws and change the culture of reflex ordering at our hospital. I felt supported in my clinical learning environment and empowered to take a meaningful experience and turn it into a sustainable quality improvement initiative. This work sparked my interest, and I decided to go beyond solving this one problem. Today I am a chief resident with a focus in quality improvement. As I transition from resident to faculty member, I strive to share what I have learned. Promoting supportive environments where students and residents feel comfortable identifying issues and independently leading innovative solutions allows them to blossom from routine clinical experts to lifelong adaptive learners. Every student and resident will meet their own Mr. Smith who motivates them to be proponents of change and improvement in health care. I see my job as providing for others what was provided for me—an environment that nurtures and supports quality improvement ideas and initiatives.

Veena Patel, MD, and Diana Stewart, MD, MBA
V. Patel is chief medicine resident in quality and patient safety, Michael E. DeBakey VA Medical Center, and instructor, Baylor College of Medicine, Houston, Texas; e-mail: [email protected]

D. Stewart is assistant professor, Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Houston, Texas.

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