Tuesday, February 24

When is "Good Enough" not Good Enough?

In response to my last entry Maddog wrote:

Every time I've taken a test in EMS, especially in a class run by the local government, everyone always says, "The only thing that matters is that you passed."

Thanks to this comment I am now in vent mode (you only have yourselves to blame for reading and commenting on this stream of consciousness crap I spew forth)…

A student in my class last night said to another (not me) “They give the same EMT card to the person who scores a 75 as they do to the person who scores a 95”. Indeed they do. The comment caught my attention as I had heard something like it before. My first year in grad school I lived with a bunch of Hopkins med students. A common statement from these guys (usually around test time and in response to someone else doing better than them) was “You know what they call the person who graduates last in the class”? ………. “Doctor”.

My Hopkins housemates were joking in that they all killed themselves to learn as much as they could and it hurt them not do well. Maybe I am misreading some of my current classmates, but a few of them seem to really have the attitude that passing is all that matters and they are pleased to get by with as little effort as possible (that is, they are under-performing their potential). They make statements indicating that they did not study because this chapter was boring or because a great episode of a favorite TV show was on or because they knew they could pass by just skimming.

I do not understand. My concern is not the test score. If you score a 70 after trying hard to master the material and the state has determined that a 70 is a sign of competence, then I am happy to ride with you and call you a brother or sister.

My concern is the effort and attitude side of the equation. How can some of us not want to put in our best effort (within the constraints of day-job, home life, etc.)? I know I am a newbie and must be naive in many ways. Maybe all I really need to know about being an EMT will come from the field and all this classroom stuff won’t matter. Even if true, though, what can the knowledge and effort hurt? How can it be a waste of time to know normal respiration rates, the differences between NRB masks and cannulas, the major bones of the body and how to describe them, etc.?

My goal is to get the patient to the hospital with as good a prognosis as possible. The thought that I will not know or perform something that is within my scope of practice and that I cost someone the best outcome possible scares the heck out of me. Not because of litigation, but because if I am going to treat people I should be treating them within the best of my abilities. Note that as far as I am concerned “best of my abilities” is NOT just of a function of the present but also the past and future. That is, I am responsible for what I have and have not learned in the past, for implementing my knowledge and skills in the present, and for learning from my current patients so that my future care can be better. I know I will make mistakes, forget things and wish I knew more. But I do have some control over these future events, and part of that control is doing the best I can in class right now. I have limitations. There are smarter people and learners better suited to the instructors teaching style. I have a professional job, kids, and social responsibilities, and some people have more and some less. But to purposely slack and try to titrate effort to just get passing scores? Again, I do not understand.

My Hopkins housemates knew their joke was a joke in two ways. First, internally they wanted to be the best they could be within reason. Second, they had external demands. They may have all been doctors at the end of med school, but they all knew that they were going to compete with other doctors from across the nation for desirable residencies. Residency programs were going to see their test scores and read letters of evaluation of their clinical skills. How much did this external motivation play a role in their work ethic (I have never seen anyone work the hours those guys did)? Are there equivalent external demands on EMTs (my volunteer corps, which is hurting for members, is not going to screen me based on my performance in class as long as I pass)? Should there be?

More importantly, does any of the above relate to being a good EMT? If not, how can the classroom experience be made to be so important to what we do in the field that everyone can agree that the effort is worth putting forth? If so, how do we set the system up so that people can see this and act accordingly?

This is all Maddog’s fault :-)