Four Plastic Tubes and What They Taught Me About Leadership and Safety

It was overwhelming.

It had already been a long day. It was my first day. I had 4 tubes of a patient’s spinal fluid. I was suddenly responsible for them. I barely knew where I was. I had little idea of what I was doing. 

But I learned quickly. 

I was doing a medical student clinical rotation at the Portsmouth Naval Hospital. Technically I wasn’t even a 3^rd year medical student yet. Honestly, I didn’t really know anything about clinical medicine.  

I was a part of the Health Professions Scholarship Program (HPSP). This is a program that covers the expenses of medical school in return for service afterwards as a military physician. The program also provided for 6 weeks per year of active duty. These could be done just for extra pay while I attended medical school, or I could do a clinical rotation at a military hospital.  I wanted to take advantage of the opportunity. I asked to do a clerkship in the summer between my 2^nd and 3^rdyears of medical school.  The 3^rd year was when you start really doing clinical rotations. I was doing this clerkship a month before that.

I had no idea what to expect. The Navy would cover my travel expenses and my lodging. They issued military orders for me. They took care of getting my flights booked. Over the phone I asked the medical education secretary where to stay. Everything was full. She suggested I try a place called “Harbor Towers.”

When my flight arrived into the Norfolk, VA airport I took a cab. I gave him the name and address of the place I was going to be staying. I had no idea what it was going to be like. We drove down the busy highway and through the tunnel into Portsmouth and then through the side streets. He pulled up to an aged and run-down building. There was trash out front and there were clothes hanging off of the balconies. My heart sank as I thought that this was what I was in for.

The taxi driver asked one of the worn looking men hanging out front and they pointed down the road. He turned around and drove down by the water to an amazing upscale high-rise apartment building on the Elizabeth River. As we pulled up, I read the sign, “Harbor Towers.” I couldn’t believe it. It was amazing! It was new and plush and beautiful. I walked inside and they checked me in and gave me a furnished apartment with a view of the river on the 16^th floor. It was honestly one of the nicest places I have ever stayed in my life.

The next day I walked to the Naval Hospital. There I got checked in and I was assigned to one of the internal medicine services. They explained to me that there were 3 inpatient internal medicine services. This meant that we would be in the hospital overnight and on call every 3^rd night. When we were on call, we were responsible for all of the admissions as well as any cross-cover issues. There would be no attending physicians in the hospital. The resident was in charge and would delegate to the interns who in turn would delegate to us (the students). The intern started assigning me patients. I had no idea what to do. And we were on call. 

As the day progressed, I learned how to write admission orders (ADOCAVANDIMPLE was the acronym he taught me). I learned about writing H&Ps. That first evening he told me he would let me help him with a lumbar puncture (spinal tap). We positioned the patient on his side and prepped and then numbed the skin. He used an enormous needle and showed me how to find the space between the vertebrae and how he could get the samples of spinal fluid. The clear fluid slowly dripped out. He collected the spinal fluid in the 4 plastic tubes that were provided in the lumbar puncture kit. 

When he was finished, he started spewing information at me. He gave me a big list of things that needed to be done. He looked me in the face and paused for effect. He told me that he did not completely trust the lab. He told me what to do to be sure that all the tests would get done. He left to go see another patient.

I was terrified. 

I labeled the tubes with the patient’s name and date of birth. I asked the unit secretary to help me get all of the different lab slips that I needed. I carefully worked on filling them out. I asked her where the lab was and then I went down to the lab. I wandered around the lab looking at signs trying to find each part of the lab like the intern had told me. When I found one that I needed, I would walk around calling for help until I could get one of the corpsmen to pay attention. It was the evening and they were not being supervised. Some of them were not very motivated. Sometimes I had to go find them and drag them back to their lab. I then handed them the tube with the respective lab slip and told them how important it was that they get the tests run. In the end I got all 4 tubes to the right places in 4 different parts of the lab.

I breathed a breath of relief. 

It had been quite a day already. I had learned a lot. I learned about medicine. But I also learned about the processes of medicine. There was so much more than what was in textbooks or that I had learned from two years of sitting in the lecture halls. In that day and night, I learned that there was a lot more to practicing medicine than just anatomy or physiology or pharmacology. I learned a lot about the practice of medicine that included everything from how to balance my time, to how to chart, to how to fill out lab slips, and to how to make sure the lab actually did what needed to be done.

Things are a lot different now. We no longer would expect a medical student to manually fill out lab slips or wander around the lab bringing tubes to each section of the lab. We don’t generally expect them to stay up all night, every 3^rdnight on call. We wouldn’t think about handing them the tubes of spinal fluid and walking off. To medical students today that likely would sound like the dark ages. 

But the challenges are still there, they are just different. Today they are more about figuring out how to use an electronic medical record. And they still have to figure out how to balance their time, how to ask for help, and how to work with the nurses and the patients and the whole dynamic that is hospital life.

Why do I share this story? Perhaps because it is such a strong memory. Perhaps it is because I know that so many of you can relate to the rapid learning that you go through when you first start doing clinical work. But also, it is because there are a couple of very strong lessons that are buried in the story.

Lesson #1: People are your most important asset:

It amazed me how determination and will can drive a broken system. The Naval Hospital was not perfect. There were a lot of flaws. But we could drive the system to work because we needed it to. We could make it work because we cared. The patients got really good care. This was regardless of a whole bunch of process problems.

I am a process kind of guy. I like to work to build processes as a foolproof way to ensure that mistakes and missteps do not happen. Process is important. Bad processes can be defeating to good people.

But in the end, the safety net still comes back to the people. If you have one person who cares – really cares – they can make up for dozens and dozens of process issues. It doesn’t mean that process doesn’t matter. But people matter even more. Keeping people who will take responsibility and own the job and ensure that it gets done is the most important thing that we can do. And if we create a perfect system but it denigrates or devalues the people who are involved, we have committed a critical sin. In so doing we have induced an amazing amount of risk. Without engaged people working the processes, the safety net has been pulled away.

I heard someone say once that they were going to create such a good system that it could make any physician practice good medicine. What was implied was that they didn’t need talent. It was only their processes that mattered.

Wrong. 

And scary.

He had great intentions. I am not challenging that. But his thinking was naïve and frankly arrogant. It showed a gap in his fundamental understanding of how our world works. Things are never perfect. Things go wrong. We have got to have safety nets in place. And the most effective safety nets are people who care about what they do.

Lesson #2: The pain and benefits of change:

That day and night were a lesson about what it means to learn. In the moment I didn’t enjoy it. It was painful. It was overwhelming. It was scary. It stretched my abilities and confidence so much that I was sure they were permanently broken. But they weren’t.

I learned so much that first day that I can still remember it even now 30 years later. It stretched and pulled me. But it also made me stronger.

That is what learning is like. If it is easy and comfortable you are not really learning. In order to learn you need to be pushed beyond your comfort level. You need to be stretched so that your muscles (your abilities) strengthen as a result of the exercise. So often we naively think that we can avoid the stretching and the pain. But that is the nature of growth. We need to remember that. We need to accept it and welcome it, knowing that the temporary pain brings growth that we will be thankful for afterwards.

I was in a meeting recently when we were dealing with change. The change was uncovering a bunch of broken processes. Fortunately, we have good people who are getting by (for now) to buy us the time to fix the processes. 

I thought about that night walking around getting the corpsmen to leave the television they were sitting by to process my patient’s spinal fluid. I thought of how I would go down to radiology to search for my patients x-rays that got misplaced. I thought about all the little things that we learned to do to check and double check that our patients were ok. I was thankful for the fact that we had good people making the system work. I am thankful that I still get to work with really good people who really care about what they do. 

In the meeting we talked about change. We talked about how this was going to make us all better. We were going to be able to provide good care to more patients. In the moment however it is no fun. It feels like we often get pushed to the point of breaking. But then we get stronger. 

I learned so much in that month in June of 1989 that I fell in love with internal medicine. We really had an impact on our patients. We did a lot of good. That was when I started to become a clinician. Two years later when I had my choice of where I wanted to go to train for residency, there was no question in my mind. I was going to go back to Portsmouth Naval Hospital. I knew there that I could and would work with good people. And I would really learn.

I was young. It was night. I was tired. I was overwhelmed. I was standing there holding 4 plastic tubes. They were 4 plastic tubes that I would remember for the rest of my life.