Friday, October 21, 2011

See one. Do one. Teach one.

 *some details changed to protect anonymity and all that stuff. . .you know the deal, people.

 "See one. Do one. Teach one."

~ Anonymous

Hands shaking inside of tight sterile gloves. Eyes with laser focus on the landmarks. All but a tiny square of skin on the small of the patient's back is blanketed in blue sheets. That exposed area, now rubbed sterile with surgical-grade antiseptic, awaits those hands.

"Your position is perfect. This is exactly correct."

The upper level resident is coaching; he is using those words of encouragement that surely were used for him. Though technically a novice at being a supervising physician, he is obviously a natural.  I smiled as I observed the entire thing--his back straight and confident and his words commensurate with his posture. I liked the way he glided between giving attention to the medical student whilst offering continuous concern to the patient.  Of course. The patient.

"How are you doing, ma'am? Are you okay? Just let us know if you are feeling pain, okay?"

And gently she'd respond, "I'm fine."

Like clockwork the student mimicked this, checking on her patient's well-being despite her trembling hands. This was the first lumbar puncture she would perform.  And perhaps, for her supervising resident not even six months out of internship, this was one of his first experiences guiding someone junior to him through it.

"Make a wheal under the skin," she spoke aloud. She wanted to be sure she followed the proper steps.

"Exactly," he affirmed.  She continued anesthetizing the narrow space that awaited the spinal needle as he nodded in confirmation.

Then, as if planned and blocked by a director, they peered over the sterile field and spoke in unison:

"You doin' okay over there?"

She paused for her patient's answer before she continued--just as she'd been taught.

"Okay, so now you may feel some pressure. I'm about to insert the spinal needle, okay?"

"Okay," the patient nonchalantly replied.  She looked cherubic all curled into a fetal position.  Mostly because she seemed content with all of this poking and prodding. Words like "T-cells" and "viral load" and "spinal tap" weren't foreign at all to this patient.  She'd been there and done that, and didn't seem to mind at all when, with full disclosure, the student admitted that this would be her first time doing this procedure.

"That's okay with me," the patient said with a genuine smile.  "You have to learn at some point."

And despite the fact that no person ever really wants to sign up for a lumbar puncture, let alone one performed for the first time by a medical student, there was a peacefulness about it all that immediately told me it would go just fine.

"Bevel up."  She continued to narrate her actions as her supervisor stood close; this time she was referring to the mouth of the spinal needle.  I liked the way he nudged her along, peppering in relevant questions along the way.

"You alright, ma'am?"


She inched the long spinal needle through her man-made welt while carefully sliding the stylus out periodically to inspect for a flash of spinal fluid.


"Watch your hand, don't lose your position."

"I'm meeting some resistance. Do you think it's bone?"

"The intervertebral space is narrow. You just need to reposition you hand and make sure she's not rotating forward or backward."

"Okay." She took a deep breath. I loved the determination in her face.

"We're almost done with the hard part, okay, ma'am? How are you doing?" her supervisor asked.

"Just fine. I'm okay."

"Pain?" she asked earnestly. The student really wanted to know and seemed to deeply care about her patient's comfort.

"No, I can barely feel anything," the patient replied.

"Okay, let me know if you do, okay?"

"I will."


She swung her head in the resident's direction, eyes widening behind the clear plastic eyeshield. First a few drops of blood and then. . .



"Now we're just going to take the samples of the spinal fluid, okay?  We're in with the needle and the spinal fluid is coming on out now."  I could hear the tremble in her voice; part relief and part elation. Her first time doing a lumbar puncture.  And she'd succeeded.  On the first time she succeeded. (Which is more than I can say about my first L.P.)

Next they collected the specimens; the resident downshifting his gears and morphing into her trusty assistant.  Diligently he handed her the numbered bottles and methodically cleaned up the sharps.

Throughout all of this, I sat quietly on a nearby chair; close enough to see everything, to chime in if necessary, and to assist if required. . . . but still far enough to let my resident lead. The residents call it "micro-managing" when attendings breathe down their throats and cramp their leadership style. I didn't want to be that person, so I crossed my legs and watched; I even answered my resident's pages for him. Sure, at one point I felt myself itching to gown up and snap on a pair of size 6 1/2 sterile gloves just for old times' sake. . .but I fought the urge staying glued to that seat and resisting that temptation.

"See one. Do one. Teach one."
That's a common saying in medical education. Classically, that's been the order of things, particularly procedures, in everyone's medical upbringing. You stand by passively those first few times. Then at some point you get the chutzpah to try it yourself, but only if the planets align and you have a supervisory resident that feels ready to both relinquish the operator position and guide you through it.  Finally, you become that person who's done this enough to remove someone else' training wheels and walk behind their bicycle.

But on this day, I recognized a shift in this unspoken law of learning in the clinical setting.  I have already seen one, done one, and taught one many times over. This time, I watched this with different eyes. I had the golden opportunity as a clinician educator to see one . . . one who finally had the chance to do one while having her tremulous hands held by a newly minted resident. . . . ready and able to confidently teach one.  Gives a whole new meaning to that old adage--it had now gone full circle.

They dismantled the giant blue force field separating them from outside germs and also eye contact with their patient.  At this point, I'd stepped out of the room, but I didn't need to be there to know what would happen next.  They would ensure the patient was comfortable and provide some anticipatory guidance about laying supine to avoid a spinal headache. They'd ask if the patient wanted her window shades opened or closed, her room light on or off, and her television muted or with sound.  And then they'd promise to share the results as soon as they were available.  And as soon as they did appear on the computer screen a few hours later, without question, they'd be standing at her bedside going into the nitty-gritty of each and every detail.

Or rather she, the medical student, would go back and do all of these things alone.  Why? Because, at some point, this is what she'd seen someone else do. At least, this is what I've chosen to believe. . . .

"See one. Do one. Teach one." 

Medicine and learning . . .all in a continuous cycle. . . .simultaneously wonderful and terrifying. . . . . yeah.

Happy Friday.

 It's official. She did one.


  1. I got to do one on my 2nd day of MS III (also my 2nd day of Neurosx). It was the best feeling ever! I imagine I was beaming just like smiling student above....

  2. Very neat feeling indeed. I love it when I can teach the residents something new whether it is procedural or something simpler like interpreting an EKG. Equally thrilling.

  3. Beautiful. I may have never done an LP but I vividly remember my first IM injection when the Vietnam Vet patient at the VA hospital flexed his deltoid muscle at the exact moment I darted the needle in and it flew right back at me. My instructor who was one of the first PhD nurses and was all of 5ft tall walked around to the the tough young man and told him if he EVER treated one of her students like that she would tell his commanding officer. He "yes Mam"ed her to death and contritely apologized to me. The patient and I became good friends until I moved on to another rotation. Ah the memories.

  4. That was a great article. Btw, I'm Sandeep's brother...feel free to whack him on the back of the head whenever he gives too much lip.

  5. Yet again, you are eloquently describing something we all (in the medical field anyway) have experienced first hand. I'm in the "middle ground" in veterinary medicine - still learning and teaching everyday - and nothing feels more inspiring than seeing my students succeed.


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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