From the Wards
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The Incompetence of Competence

It was 3 a.m. in the emergency room. I had the ultrasound probe in my hand and was searching for a 50-something-year-old man’s bladder. He had not been able to urinate for over 10 hours and was in terrible pain. I figured his bladder had to be the size of a basketball by now. I stared intently at the black and white fuzzy screen, trying to interpret the landmarks. I did not see the large area of darkness that I was expecting for the bladder and continued to slide the ultrasound probe around. I angled it to the right, to the left, superiorly, inferiorly. I pressed deeper, I released pressure, all the while staring at the screen trying desperately to find the poor man’s bladder before he either slapped me from the pain or started calling for someone else to do it. The resident I was working with stared at the screen and gave me some tips – suggesting me to go the right, back to the left, then down – but we still did not see it. Both the resident and I looked down at the probe simultaneously, and he said with a slight smile, “I don’t think we’re going to find it there.” I turned a dark scarlet color and quickly removed the gooey probe from the top of the man’s penis.  The patient just looked confused.

I was watching a lower anterior resection surgery with another medical student. The surgeon turned to my colleague and asked him to put on some gloves and insert an anoscope, even though he was not scrubbed in. The patient was a morbidly obese man and my fellow student was having difficulty finding the appropriate location to insert the scope. The attending surgeon and resident had some fun with the student as he struggled to find the anus. Meanwhile, I performed my medical student duty and held a pair of scissors to try to cut the suture. I say I tried because I cut and cut multiple times but the godforsaken scissors would not cut through the suture. The attending shook his head and said that he was proud to be in the company of the best and brightest on this fine day. We later lamented our incompetency and laughed about it, deciding that surgery was not for us.

Medicine has a way of making the easiest things in the world difficult. Cutting a string, finding the anus or bladder, and just about everything else that has a technique to it. Physicians are among the most trusted, respected and well-regarded members of society and yet they start off having difficulty using a pair of scissors. Patients often see them as infallible: having endured years of rigorous training, sleepless nights, and having read volumes of books. But we make mistakes during that process of rigorous training, with the goal being that they occur during the years where we have backup and oversight. Medicine has been and probably always will be a field that is based in experience more than anything. Repetition and variety of patients are as crucial to learning medicine as any textbook or journal will ever be. There is currently a huge push towards evidence-based care, which is perfectly appropriate, but it is difficult to apply evidence to every single patient that you encounter. They have their individual stories, individual medical problems, social issues and personalities. The evidence-based guidelines are just that, and it is still the physician’s judgment, insight and experience that will lead to the appropriate diagnosis and treatment decisions.

The competency that we obtain is only by trudging through years and years of incompetency and mistakes. New curricula have been developed and work-hour restrictions have been implemented to try to soften the process but it simply comes down to time. As the incompetency lessens, we are given more and more responsibility and go from cutting string to removing organs. While all types of work require experience to improve, medicine is so unique in the trust that patients place in our knowledge and judgment. As medical students, residents, and fellows, we will all continue to work ourselves into the ground to try to provide patients the best care that we can give. Ultimately, we will be rewarded with our patients’ trust.

Even as a fourth-year medical student, I think back to the incredible growth that has occurred over the previous four years.  It gives me faith going forward into residency knowing that when I look back on things four years from now I will be a capable and outstanding physician. My mountains of incompetence will have become molehills of competence.

Andrew Petersen (2 Posts)

Contributing Writer Emeritus

University of Cincinnati College of Medicine

Andrew hails from Thousand Oaks, CA and studied psychology and integrative biology at UC Berkeley. He is now a Class of 2013 medical student at the University of Cincinnati and is planning to match into internal medicine.