Procedural Competency

I walked into the exam room with my preceptor and greeted Mrs. and Mr. M warmly, already familiar with their faces as this was the third visit in three weeks for Mrs. M to get bilateral injections of Orthovisc (a substance called hyaluron shown to maintain joint fluid and support cartilage), into her knee joints. She had been diagnosed with severe degenerative joint disease of both of her knees, and was hoping this series of injections would eventually decrease her pain and increase her activity. She hopped up onto the table, and instinctively grabbed her husband's hand, as she had the previous two weeks. My preceptor asked her which knee she wanted done first, after which she glanced in my direction, and asked if I could do one of the injections. The previous two weeks the sports medicine fellow had been present in the room, and had done the other knee simultaneously so that she didn't have to suffer through the procedure twice. On this third visit she wanted the same as the previous two: the shortest and least painful procedure possible. My heart immediately began to beat fast, both from excitement at the opportunity, and total fear of incompetence at the same time. My preceptor reminded her that I was a third year student, and she asked me whether I had ever done an injection before. I replied I had not, but had watched several. She then asked if I would like to do one knee, to which I replied, "Yes I would love to," smart enough to not turn down a gift when it was offered. Her husband was visibly upset with the thought of someone new like me doing this, but she reassured him by saying that I needed to learn, and in order to learn I needed to practice. Talk about the perfect patient!

The next five minutes was a blur as I struggled to hide my rapidly beating heart and mildly shaky hands. I had seen this injection done, on this very patient, two times prior, and was confident that the needle would go right where it was supposed to. I marked the spot where the needle would insert, confirmed it with the "real" doctor, sterilized the skin, shakily opened up the syringe of Orthovisc, and attached the needle. One, two, three, and we both inserted our needles into this woman's knee joints. Fortunately for me, although not so for the patient, the knee that my preceptor was injecting was full of osteophytes (bony overgrowths that crowd the joint space). Subsequently he had to maneuver his needle all around, all the while she's blurting out "ow, ow, ow, ow," blowing out her breath like she was in labor, and squeezing her husband's hand white. My needle entered her other knee joint effortlessly, and the injection was over quickly. We placed band-aids over the little pin pricks, and off she limped out of the clinic.

My heart took some time to calm down, and as I wrote up the procedural note, many different thoughts struggled for center stage in my mind. Initially I was incredibly excited at having had this opportunity to perform such an "invasive" procedure, particularly as a third year medical student. In addition, I thought about what would have happened if my needle had also gotten stuck on osteophytes. This was not a pretty picture in my mind, as I imagined myself turning white, heart doubling in cardiac output, followed by a desperate glance over to my preceptor with the signal HELP screaming from my eyes. While I did have the confidence to slide the needle into a joint free of complications, I definitely was not trained at how to handle bumps in the road. How many injections into a knee joint would it take for me to not have shaky hands, and also, to know how to confidently handle potential complications?

Finally, I wondered what it was about the patient that allowed her to let me "practice" on her, and whether or not it was just a matter of her wanting to avoid the pain of a second injection. Was it something I had done in my previous two interactions with her? Was it the unspoken confidence my preceptor had in my abilities? Was it that she was aware of my previous career as a massage therapist, or my future intentions to be a physical medicine doctor? Why did she trust me, not yet a "real" doctor? In short, what does it take to have procedural competency from the point of view of the patient, as well as from a deep internal sense of confidence from within the physician?

This patient encounter occurred several weeks ago, and I continue to think about procedural competency as I do a rotation in Bend in physical medicine and rehabilitation, the specialty I plan on going into. I have seen tons of injections here, and I've only worked for 6 days so far. I've seen injections of knees, shoulders, hips, muscle trigger points, and spinal joints. At first it looks complicated, especially the spinal injections which take place with the guidance of xray. Every day it looks easier although, as I learn the bony landmarks that are palpated prior to an injection of a shoulder or knee joint, or as I learn to decipher the shades of gray shadows on the xrays. I realize that it's a numbers game. The more you do, the better you get, and the more confident you become. I am happy to say that I can imagine myself, someday, injecting joints of the human body, with confidence and a sense of satisfaction with helping my patients in pain. I look forward to a future filled with learning how to perform these procedures competently, and I thank in advance all the patients that will help me become a proficient physician. Cheers!