Training, and the repetitions that are inherent in training, are essential not simply for establishing the ability to perform a particular action or procedure but even more, in learning how to troubleshoot the complications and inherent variations within a procedure.
The first step in overcoming a complication is recognizing that a complication has occurred. The ability to recognize that something is off, that there is something wrong in the first place, is dependent on knowing and being able to recognize normal. The ability to recognize genuine currency, gems, works of art, or designer products is established by constant and vigilant examination of the real thing. There are a near-infinite number of ways for a forgery to be made, and yet only one way to be the genuine product. Likewise, particular skills require repetition in the proper manner to establish the correct baseline from which everything else is built. Normal is the baseline for encountering and managing all variations and complications. Understanding the abnormal begins with understanding the normal.
From this base, variations and complications from that perfect base are recognized, mitigated, and managed. Experience is largely a function of having put in the time and repetitions to have seen many variations, many complications, and many outcomes, both good and bad. Experience means having seen times when people pushed on and went too far, times when people turned back too early, and times when people simply lost their way completely. The pictures of the human body that appear in medical textbooks rarely represent the actual patient. The position, origins, and shapes of vessels often vary significantly from person to person. This requires significant experience to be able to recognize these variations, adapt to the new anatomy, and understand whether the variation that one sees in front of them is responsible for the symptoms or pathology that is being observed by the patient. A structural abnormality may represent inconsequential variation, pathologic variation that impairs function, or physiologic adaptation to a particular stress or pressure from the environment. In the latter case, attempts to correct that adaptation will likely cause greater harm as the initial stress is now left uncompensated.
Experience is required not for the times that go well, but for the times when one hits resistance, when something is not going according to the textbook. Placement of central or arterial lines are good examples. During the ideal procedure, everything is smooth, with little resistance during every step from the advancing of the needle to the passing of the wire to the dilation to the placement of the catheter. When this happens everyone feels good and anyone could place the line. It is the variations of this ideal scenario that requires training. Perhaps the patient is moving around, perhaps CPR is being done on the patients such that the whole field is moving. Perhaps resistance is encountered at one or all of the steps. Is the resistance normal and one should continue advancing? Or is the resistance problematic requiring the procedure be aborted and another site chosen. How does one troubleshoot the resistance to minimize the risks of complication and improve the odds of success? Experience, seeing repetitions from all forms of variation provides the tactile background for feeling the resistance as well as the intellectual understanding of how normal, physiologic, and pathologic may present.
The need for long hours and many years of training is not for the good times, rather it is for the bad times, the times when one is unsure whether to proceed or how to proceed. There is no textbook to turn to that accurately represents the actual individual patient. Instead experience, putting in the repetitions over many years is the requirement for understanding and managing these variations and complications. Experience addresses complications, yet complications also build experience in a momentous cycle of building proficiency and expertise.
JR.Stanley 