Posts Tagged ‘PICU’

Should families be allowed, or even encouraged, to watch CPR?

Should families be allowed, or even encouraged, to watch CPR?

May 11, 2013  |  General  |  1 Comment

This is a topic that comes up from time to time for often spirited discussion. The most recent example comes in a a couple of articles in the New England Journal of Medicine. One was a research paper; the other was a pro and con discussion.

The research paper studied cardiac arrests that happened outside the hospital. The authors tested the premise that allowing families to watch the efforts of the medical team reduce their psychic distress later. One group of patients received usual care, which meant keeping the families away from what was going on. Families of patients in the other group were asked if they would like to observe the resuscitation up close: 79% chose to watch. A medical team member was assigned to be with them and explain everything that was going on. The researchers then followed up with the families 90 days later to determine how many had symptoms of anxiety, depression, or actual post-traumatic stress disorder.

The investigators found a significant reduction in psychological symptoms among family members who had watched the CPR. Also important is that there was no problem with family members interfering with the medical team.

Now comes the controversy. Family observation of CPR is a hot topic among critical care and emergency physicians, and opinions are strong both for and against. This is shown in the next article. It is short — a case scenario of a cardiac arrest, and is well worth reading if you don’t know what we actually do in those situations. Two experts then wrote brief pro and con statements about allowing families to watch. But it is in the comments where things really heated up. Here are some examples:

Being present is more harm to the family

A genie that should not have been let out of the bottle

No family presence for me!

Absolutely no — apart from the chaotic scenes of CPR, I don’t want to be accused by the family bystander that I killed their loved one, do you?

Don’t deny families who choose to be present –support them

Being present far more important for all.

Yes, I support family presence at the bedside during a code situation

And so on, for nearly a hundred comments. Scanning them over, they seem pretty equally divided. I assume the commenters were talking about adults, but this issue always comes up when we have a CPR event in the PICU. For pediatric intensivists, the question of parents observing is I think less devisive. I always ask families if they wish to leave or would like to stay with their child. Nearly all choose to stay. I have heard many times afterwards that they were glad they had the opportunity to participate in some small way. Nearly all the pediatric intensivists I know feel the same way.

I have never had a problem with parents interfering with care in any way. But the demeanor of the team members, especially the physician directing the resuscitation, is key. Resuscitations are stressful — and messy, too. But shouting never helps anything. A calm, firm demeanor is what parents need to see, especially in the doctor. So do the other team members. I’ve been doing this for 30 years and have seen my share of chaos. The way to control that is practice, practice, practice: mock codes keep everybody sharp.

It is crucial, however, that someone be delegated to stay right by the parents and explain what is happening. Usually I designate an experienced PICU nurse, who needs to be ready to support the parents emotionally — physically, too, which means finding chairs or stools as needed. Every parent I have ever dealt with in this way has been grateful afterwards for being allowed to stay.

Maybe adult patients are different; I have no experience with that. But I think parents of a child should always be given the option. It the resuscitation is unsuccessful, it is a good way to assure them that everything possible was done to save their child.

If you’re interested in this issue at all, I highly recommend you read the pro and con piece linked above, especially the comments.

Commercial cold medicine for young children? Just don’t.

January 21, 2013  |  General  |  No Comments

I’ve written about this before, but it’s well worth doing it again. It’s once more cold season, bringing up the question parents commonly face: Should they buy one of those rows and rows of cough, sneeze, and runny nose medicines one finds in every drug store and supermarket? In a nushell, no — none of the preparations sold over-the-counter to treat upper respiratory infections in children work, and all could be dangerous. That’s the conclusion of a report some years ago by the Food and Drug Administration, one still worth reading. You can read about the details, as well as the history of how and why these cold remedies were regulated in the past, here.

There is a huge market for these products. Ninety-five million packages of them are sold each year, and drug companies spend millions of dollars marketing them in various ways. The implication of the advertising is that these preparations (most are mixtures of several things) are safe.

In fact, they are not. Poison control centers receive thousands of calls about them every year, and The Centers for Disease Control found that many are seen in emergency departments owing to their side-effects. The FDA even found 123 deaths linked to their use. Possible side-effects can include hallucinations, dangerous over-sedation, and serious heart rhythm disturbances. Over the years I myself have cared for several children in the PICU who had serious side-effects from them.

The problem isn’t just over-dosing errors. The problem is we don’t know the correct dose for children, and estimating how much to give from adult doses is misleading and dangerous. The fundamental problem, though, is that they just don’t work. In fact, a total of six carefully randomized studies testing these agents in children under twelve all showed they worked no better than placebo — in other words, a sugar pill worked just as well. So using them puts a child at some risk with no benefit.

The Food and Drug Administration has issued a public health advisory that they not be used at all in children less then two years of age. They left use in children older than two alone, but I wouldn’t use them for those children, either. They don’t help, and may harm.

If you have questions about cold preparations, by all means talk to your child’s doctor about it. But the growing consensus among physicians is simple — don’t use them in small children.

The balance between optimism and false hope in PICU practice

November 26, 2012  |  General  |  No Comments

A recent little essay at KevinMD entitled “Do patients bond best with doctors who misinform them with optimism” got me thinking about balancing honesty and optimism in practicing any medical specialty in which patients not infrequently die.

Tragic things can happen in the pediatric intensive care unit. Anyone who works there — doctors, nurses, respiratory therapists, and many others — see these tragic things. Children are there who are seriously ill or injured, and some of them die. I’ve been practicing pediatric critical care for 30 years and I long ago lost count of the number of children I’ve seen die in front of me. When I meet someone new and they find out what I do they often ask me how I do it, often adding that they never could. More than a few of these people are physicians. My answer is that I don’t really see the question in the same way that they do.

For one thing, tragic things happen whether or not I’m personally there to see them. Tragedies are a part of life, and I have the privilege of participating in that aspect of life. The experiences I and my fellow intensivists have in our work are now unusual, but once they were common — they were shared among most adults a century ago. So, in a way, what I participate in with a child and the family has been usual for far longer than it has been unusual. That’s what I mean when I say that participating in these human events is a privilege. It really is.

I am an optimist. Even when the chances of a child’s good outcome are long, I can still proceed optimistically. I can even show my optimism to the child’s family. But, of course, I must also be honest with the family — if the situation is dire, I need to tell them that. But I don’t think those two things are contradictory. I don’t think I hold out false hope, but I do tell families that I’m hopeful.

This way of practicing goes against a common technique of PICU practice, one which many call “hanging crepe.” The idea is that the doctor can be hopeful and optimistic with families until the outcome begins to look increasingly ominous. At that point, to prepare families for the probability of death, the doctor becomes progressively more pessimistic with them. I think that approach underestimates the ability of families to discern for themselves that things are not going well —  nearly all do. (Like everything in medicine, there are exceptions. In my experience, families who have trouble with this approach are already highly dysfunctional or have parents with their own cognitive issues.)

In essence, I think most families easily adopt what is really the common sense approach humans have used for millennia in the face of critical illness: realistic about the chances, but still optimistic. The physician’s job is to tell families (and children) what we know about the chances, but there is no reason not to remain optimistic, too.

New guidelines on treating strep throats and on tonsillectomy for recurrent strep throat

October 15, 2012  |  General  |  4 Comments

There are some important new recommendations both about strep throats in general and about tonsillectomy — taking out the tonsils — as a treatment for recurrent strep throats.

Some of us can recall a time when getting your tonsils out was one of the rites of passage of childhood. Usually a related procedure is added — an adenoidectomy, removing the adenoids as well. It’s called a T&A in the medical world, and it’s one of the most common surgical procedures done on children.

Where are the tonsils, what do they do, and why would we take them out? The tonsils are at the back of the throat, one on either side. If they haven’t been removed, you can see them peeking at you when you open your mouth wide and look in the mirror. Both are part of your immune system, similar to lymph nodes (the “glands” you can feel at the front of your neck). As part of the immune system, the tonsils fight infection; they are first line of defense in the throat, and when they are doing their job fighting infections, you get a sore throat. The tonsils usually swell a bit and get red when that’s happening. Here’s a picture of them:

The connection between tonsils doing their job and strep throats is that a common cause of tonsillitis in children is a strep infection. Before we had antibiotics, removing the tonsils was one way to combat recurrent strep infections. As soon as penicillin, one of the first antibiotics, came along, though, we instantly had an effective nonsurgical treatment for strep tonsillitis. Nearly all of the time it works, primarily because the strep bacteria has maintained its sensitivity to penicillin — we haven’t seen the antibiotic resistance that bedevils our ability to treat other bacterial infections.

Nearly all strep throats happen in children older than two years of age. Strep infection is very unlikely in a younger child with an inflamed throat; in toddlers they are nearly all caused by viruses, which antibiotics don’t help. Children beyond that age do get a lot of strep infections, and some children have recurrent strep, sometimes multiple times each winter. For those children, doctors often recommended taking the tonsils out. Before I went into critical care, I first trained and practiced as a pediatric infectious disease specialist, and I was consulted many times about such children. My bias was nearly always against tonsillectomy. My reason, shared by most infectious disease experts, was that we have effective antibiotics to treat strep. Why risk the surgery?

A key point is that recurrent strep tonsillitis nearly always gets better with age no matter what we do. This makes tonsillectomy look good, because the natural history of the illness is to improve. I’ve met dozens of parents who say their child (or themselves as children) had constant strep infections until the tonsils came out. Often these same parents (and especially their grandparents) had had their tonsils out as children and more or less regarded tonsillectomy as something children need, like vaccinations. But frequent courses of penicillin, one of the safest medications on the planet (if your child is not allergic to it, of course), nearly always ultimately lead to the same favorable result as the tonsillectomy. (If your child is allergic to penicillin, we have other safe options.) This is why the Infectious Diseases Society of America, the professional group of specialists in infectious diseases, has made these new recommendations.

The important thing to remember is that tonsillectomy, like any surgery, is not without risk. It’s not just a routine thing like getting a vaccine shot. Compared with other surgical procedures the risk is low, but it is not zero. There are risks of bleeding afterward, sometimes life-threatening, and there are other risks associated with the anesthesia needed. Every year I see at least one child in the PICU who has suffered a complication from a tonsillectomy.

There still is a place for tonsillectomy for some cases of strep. Abscesses around the tonsils are one example. Tonsillectomy can also be very helpful for persons whose tonsils are so large that they block the airway, especially when they sleep (a condition called sleep apnea). But for the bulk of children with recurrent strep throats, it’s generally best to wait it out, treating each infection with antibiotics.

With everything we do in medicine, it’s important to weigh the benefit of the treatment against its risks: for recurrent strep tonsillitis, most of the time the calculus favors antibiotics. The importance of these new guidelines is that such a viewpoint is now the standard one.

The Electronic Medical Record (EMR) and the Eclipse of Patient Stories

October 10, 2012  |  General  |  1 Comment

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this is a good thing because the EMR has the ability greatly to improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over too often barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important things. With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy.

I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. The EMR is overall a good thing. Yet there is a problem with the EMR: it is trying to serve too many masters. The needs of these various masters are different, and their needs are sometimes incompatible, even hostile to one another.  These masters include other caregivers, the agencies paying for the care, and those interested in medico-legal aspects of care. What can happen, and I have seen it many times, is that the needs of the caregivers take a back seat to the needs of the payers and the lawyers. The EMR is supposed to improve patient care, but sometimes it makes it worse. Physician progress notes are an important example of how this can happen.

Progress notes are the lifeblood of the medical record. They tell, from day to day, what physicians did to a patient and why. They are a narrative of the patient’s care. Three decades ago we sat down, pulled out a pen, and wrote out our daily progress notes. There were standard ways of doing this, but physicians were free to organize their notes however they liked. That was both a blessing and a curse. It was a blessing because not all patients fit the standard way of note writing, so you could modify how you recorded things; it was a curse because every physician was different, and some wrote very sketchy notes indeed, notes from which it was very difficult to figure out what happened. I once did a research project for which I was reading physician notes from the nineteen twenties, thirties and forties. I recall one patient in particular who was clearly desperately ill. He had critically abnormal vital signs (which I could tell from the nurses’ graphic chart), needed several blood transfusions, and even stopped breathing once. His progress note for the day, written by a very famous and distinguished physician, was one line: “Mustard plaster didn’t work.”

Physician notes have evolved a great deal since 1930. Certainly in my medical career, which began in 1974, physicians were expected to make some reference to what they were thinking, why they did or did not do what they did. Sometimes the notes were cryptic jottings that made it very hard to follow what was happening. But most of the time you could understand what your colleagues were thinking. But if this worked reasonably well for physicians, other users of the medical record complained loudly. Payers, such as insurance companies and Medicare, based their payment upon those notes. They were unwilling to pay for anything that was not clearly documented. They also increasingly based their payment structure on the complexity of the medical decision making; if physicians wanted to be paid at a higher rate for managing a complex and difficult patient they needed to show in their note just why that patient was complicated. They needed to show what they were thinking, and what information, such as laboratory data and the physical examination, they used to make their decisions. Finally, for the lawyers, the operative phrase was “if it’s not documented, it didn’t happen.” In theory, the goals of all three users – caregivers, payers, and lawyers – should be in alignment. But with the EMR the needs of the caregivers, which should be paramount, are losing ground.

The EMR, since it is on a computer, can be manipulated in all the ways a computer allows. Hospitals are laying out millions to implement the EMR, and to ensure maximum payment they want to make sure it is easy for the payers to find in the EMR all the things the payers want there. This is accomplished, among other things, through the use of templates and “smart text” for progress notes. For example, a physician writing a progress note in Epic, a popular EMR system, can open a template that has many components of the evaluation already filled in. The program can bring into the note all the previous laboratory values. It has all the categories of the physical examination sitting on the screen for the physician to fill in. It is easy to “drag and drop” information from previous notes with simple keystrokes. There’s nothing intrinsically wrong with all this. It can make producing a complete progress note quick and easy. But it also can destroy the original purpose of the progress note – to give a narrative of the patient’s progress. It can stifle the conversation between physicians embodied in traditional progress notes.

Recently I saw an example of the problems this can cause. A couple of weeks ago I heard I was getting a patient into the pediatric intensive care unit with multiple problems, most acutely a blood problem. One of these lesser issues was a heart problem that required surgery. Because of the other serious problems, though, the surgery had been postponed for the future. I read about all this in the patient’s EMR before she even arrived in the PICU, which is one of the great aspects of the EMR. We no longer have to wait for a clerk pushing a cart around the hospital to deliver the paper chart. The patient had been seen just that morning by her hematologist for the blood issue and the progress note in the EMR told me the plan for her heart problem was surgery sometime in the future when the child’s other problems had improved. It said so right there on the screen. In fact, all the notes had been saying that for over a year. So imagine my surprise when I went in to see the child and saw an obvious and well-healed surgical scar on her chest, clearly from cardiac surgery. She had had her heart fixed two months before at another institution. I gave her hematologist the benefit of the doubt and assumed her doctor knew the surgery had been done, and that what had happened (I hope) was that the doctor had used the beguiling convenience of drag and drop on the progress note template to do the note. This particular incident was innocuous, but I think you can see the potential for mischief with this sort of thing.

This is not an isolated event. I have seen many examples, so many that I now cast a suspicious eye on all those uniformly formatted progress notes. The ease with which mounds and mounds of verbiage and laboratory data can be stuffed into a progress note may give the payers what they want, but it often does not give me what I want, and that is some evidence that all this information was processed through a physician’s brain and led to a carefully considered decision about what to do. I want a human voice, and that is getting harder and harder to find in the EMR’s stereotypic and bloodless documentation.

Medicine is about stories – patients’ stories. I was taught forty years ago that most of the time the history gives us the diagnosis. Osler reputedly said: “Listen to the patient. He is telling you the diagnosis.” (That attribution has been questioned, but the spirit is definitely Osler’s.) Of course these days our wonderful scientific tools often give us the answer, and I certainly do not wish to toss all those things aside to go back to using only what Osler had. But medicine is not really a science. It is based on science, uses science, and is increasingly more scientific. But medicine also contains large measures of intuition, educated guessing, and blind luck. I do not think that aspect will ever go away completely. When I read (or wade) through a patient’s record, I look for the story. When I cannot find a coherent story, I cannot give the best care.

For myself, even though I of course use the EMR, I refuse to use all those handy smart text templates. It takes me longer, but I type out my progress notes, organized as I did when I used a pen and chart paper. It takes me a little longer, but it makes me think things through. No billing coder has ever complained. More than a few colleagues have told me, when seeing shared patients, that they search through the EMR to find one of my notes to understand what is happening with the patient. I recommend the practice.

Less has changed than you think: the role of “watchful waiting” in the PICU

July 15, 2012  |  General  |  No Comments

Offhand you would not think a child with severe viral pneumonia and one with a major head injury are much alike, but they are. Together they illustrate a great truth of pediatric intensive care medicine, which is much of what we do is not specific treatment for the child’s problem; rather, it is what we term “supportive care,” because it supports the continued functioning of the child’s vital organs and systems while the problem runs its course and the child heals.

Both of these children often require very sophisticated technology to provide that organ support, things like mechanical ventilators and devices for measuring pressures inside the brain, but that technology doesn’t actually cure anything. But if it doesn’t cure anything, what does it do?

One of the most important principles of supportive care in the pediatric intensive care unit is that we make sure what we are doing does not make the problem worse. A good example of that is the child with a severe head injury. Although there are a few things we do to help the situation, a key aspect of what we do is the maneuvers we go through to make sure the brain is given a chance to heal without further stresses. For the child with severe pneumonia, the sort of child who is often on a mechanical ventilator machine, we do a similar thing — we use the machinery in such a way to minimize the chances that the ventilator itself does no harm, although this is not always possible.

This kind of watchful waiting at a sick child’s bedside is something parents have done for millennia. What the PICU often offers is simply an updated version of that time-honored vigil. So really, in key ways not much has changed for centuries. Doctors — and parents — just have to wait and see how things turn out.  Of course we have much more to offer in supportive care than my physician grandfather had a century ago, but the key principle is the same.

The Affordable Care Act and the PICU: How ObamaCare impacts children in the PICU

June 29, 2012  |  General  |  No Comments

It’s the day after the drama surrounding yesterday’s Supreme Court decision upholding the ACA as constitutional. As legions of reporters and bloggers have written, the law has far-reaching effects. In my corner of medicine it will greatly help (already has, really) a small but not insignificant number of children and families. These families are those who have a child with a severe chronic medical condition.  Many of these these children spend time in the PICU. This is because they are fragile little people, and the least bump in the road can make them very ill very fast. A good example would be a child with severe respiratory problems such that he requires a tracheostomy and a home ventilator. When a child like that gets a simple cold he can deteriorate very quickly and wind up in the PICU for a few days at least.

I’ve written before about how the percentage of children in the PICU with Medicaid is much higher than it is for children in general. There are several reason for this. One is that children from poorer families are just more likely to become critically ill. People debate why that is so, but surely a key reason is that their access to care is not optimal, so things requiring ongoing care (asthma or diabetes, for example) don’t get taken care of until the child gets very ill and they land in the PICU.

There is another reason so many of these medically fragile children are on Medicaid. Until the ACA, a child could be booted off his family’s health insurance policy if his lifetime medical costs reached a cap set by the policy. What happened then? Or what happened in the not uncommon situation in which the family changed insurance policies, say from a change in jobs? If the parents were obliged to buy their insurance on the open market, common among self-employed people, their child’s “pre-existing condition” (a horrible term) would make it impossible to get insurance coverage for him. Then what? A common approach was to apply to the Social Security Administration to get the child labeled as disabled and qualify for supplemental security income support. If the family could accomplish that, a process that can take years, Medicaid coverage comes automatically. If not, then the family had very few choices. Some went bankrupt. I have seen that happen.

The previous system, in effect, allowed insurance companies to off-load children onto the public system who were expensive to the company; it limited their exposure. That’s not what Medicaid was designed to do, and it’s not fair to the family or to the rest of the public.

So whatever else the ACA does, it makes life much easier for many children I treat and their families.

The right size for a PICU: is bigger always better?

May 1, 2012  |  General  |  No Comments

I’ve worked in several PICUs over the years. Some were as large as 36 beds (which counts as pretty large in the PICU world), and some were as small as 4 beds. Inevitably, larger PICUs can offer services that smaller ones cannot. This is particularly the case with more specialized services, like some kinds of surgery and access to super-specialists. When I’ve been in a smaller unit, there have been times when I’ve needed to transfer children to a larger one so they could get these more esoteric services. When I’ve been in a larger unit, I’ve received transfers of kids like that. Would these children who needed transfer have been better off going to the larger PICU in the first place?

The dilemma for smaller PICUs is that they can never become as experienced in caring for children with rare conditions, and it is hard for someone working in one of the smaller units to keep their skill levels up. Research has shown, not surprisingly, that physicians who do the same thing a lot are better at doing it than physicians who don’t do it so often. On the other hand, transferring a child from a local, smaller PICU to a bigger one is often hard on families, since often the larger unit is in another city — sometimes in another state. And many PICU problems can be handled just fine in a smaller place, nearer to home.

The process of transferring a critically ill child — by ambulance, helicopter, or airplane — carries risks, too. These risks are not just those inherent in traffic or flight. I can tell you from personal experience that no matter how much supplies and equipment you bring on the transport, you still can’t recreate a PICU. And the simple working environment of a transport vehicle, especially a helicopter, is cramped and noisy — far from optimal. So sometimes a critically ill child is safer staying where they are, at least until they can be made more stable.

What to do? As pediatric intensivists, we are sort of feeling our way as we figure this out. Most smaller PICUs have formal or informal relationships with larger units to which they can send children they cannot handle. But these relationships are a patchwork across the nation — we simply don’t know the ideal size for a PICU. When PICUs began several decades ago they were rare, found only in large children’s hospitals. In those days people’s expectations were different about what smaller community hospitals needed to provide. In today’s world, we believe all children should have access to the same life-saving PICU care. So smaller hospitals began to open PICUs to provide that care as best they could. Someday PICU care may be truly regionalized, with formal relationships between big and small units in the region, complete with standardized criteria for appropriate care at one unit or the other. We don’t have anything like that yet.

What parents should realize is that there are differences between what a smaller and a larger PICU can do. If your child has a particularly unusual or difficult problem, it is never inappropriate to ask your child’s doctor if transfer to a larger unit makes sense.

Alarm fatigue: or, the monitor that cried

Alarm fatigue: or, the monitor that cried “wolf”

March 28, 2012  |  General  |  No Comments

If you’ve ever been inside a PICU, or any ICU for that matter, I’m sure you were surrounded by fancy-looking equipment. There are monitors coming off the wall that measure a large assortment of patient variables. These can include include heart rate, breathing rate, blood pressure, amount of oxygen in the blood, amount of carbon dioxide in the patient’s breath. If the patient has various invasive monitoring devices in place in the bloodstream, or even in the brain, the monitors measure pressures inside the blood vessels and brain. Most of these monitors also display a waveform of these things moving across a screen in multiple colors. It’s very impressive-looking. If the patient is on a mechanical ventilator, a breathing machine, it has monitors built into it, too. This child has a bunch of those, including the brain one.

We use these monitors to measure important things, and they all have alarm settings that go bing or bong, often quite loudly, if the thing the monitor is measuring drifts outside whatever parameters are set for the monitor. That’s for safety. But many of those monitors are so sensitive that one or another of them is always making noise. Nurses are frequently resetting one or another of the alarm buttons. Virtually all the time it’s a false alarm in that the particularly bing or bong is not significant for the patient. Often it means there’s something amiss with the monitor.

I think you can see where this is going — alarm fatigue sets in. With so much alarm noise, most of it like the proverbial boy calling wolf, it can be a problem when to know when there’s a real wolf in the room. The FDA has recognized the problem, which I can tell you from practical experience is a real one, by scrutinizing new medical equipment for a balance between alarm sensitivity and usefulness. You can read more about that here.

The best advice for doctors and nurses in dealing with this issue is what the good ones always do: when some alarm goes off indicating a problem, look at the patient more than the monitor.

What works better in training medical students, carrot or stick?

February 11, 2012  |  General  |  No Comments

Like many of my colleagues, I teach and supervise students, residents, nurses, and respiratory therapists. I’m also the medical director of a PICU. Overall, I’ve been teaching and doing administration for over 30 years. And, like most of my colleagues, I never received any formal instruction at all in how to do these things. To some extent I got help from my own mentors, primarily by watching what they did, but basically I learned on the job. I hope I am reasonably good at it, but really, I have little way of knowing if I am. So I’ve always had an interest in whatever tidbits I could pick up in teaching theory that might be useful. One particular topic that’s always interested me is the opposing pros and cons of reward versus punishment. I use those tools to train my horse – rebuking bad and praising good behavior. What do we know about applying them to people?

The practical problem, one faced by most teachers, is what to do when a student does a poor job. The tradition in medical teaching, certainly when I was in training, was to lean heavily on the rebuking, punishing side of the equation. Public ridicule was common, and there was more than a little yelling involved. Did fear of that help me avoid doing the wrong thing next time?

A while ago I was reading one of my favorite group blogs, Crooked Timber. Most of the contributors are professors of one sort or another, and the topic of effective teaching comes up now and then. This whole reward/punishment tension was the topic of a post there. The situation it describes involves military flight instructors, who universally believed that yelling at fledgling pilots when they made mistakes was much more likely to make their next attempt better than was praising a good action. Here’s what one instructor had to say about it:

“On many occasions I have praised flight cadets for clean execution of some aerobatic maneuver, and in general when they try it again they do worse. On the other hand, I have often screamed at cadets for bad execution, and in general they do better. So please don’t tell us that reinforcement works and punishment does not, because the opposite is the case.”

It’s a military example, but training doctors has traditionally been done using that sort of get tough model. I was aware of a statistical principle called the regression to the mean, but this example applies it to teaching in a way I hadn’t thought about. The argument goes like this.

If a given student does a bad job at something, that is more likely to be a low point for them, below their average. Statistically speaking, they are more likely to do better on the next attempt no matter what the teacher does. So the teacher is likely to think whatever he or she did – screaming, for example – as causing the improvement. On the other hand, if a student does an exceptionally good job, the same regression to the mean makes it likely the next attempt won’t be as good, so whatever the teacher does – in this case praising – tends to cast doubt on the usefulness of praise.

For myself, I think praising, in the long run, works much better. I’d be interested in what any professional teachers think about this.

In the comment trail to the article, the classic The Art of Raising a Puppy was cited as a useful source. I found that very interesting. After all, to those of us with more than three decades in medicine, medical students are a little like puppies. We want to give them a sound foundation and train them without hurting them.