Most patients would be horrified that some physicians adopt new medical procedures with very little training. The concept is called, “see one, do one, teach one”—meaning that physicians are used to watching a procedure, then performing it, and then declaring themselves expert enough to teach it. This morning I’d like to discuss why this needs to change and how, right now, this scary concept is rampant in the orthopedic stem cell education.
See One, Do One, Teach One
The origin of this phrase is believed to be William Stewart Halstead, MD—one of the fathers of the modern surgical-residency-training program in the United States. Back when doctors were perceived as infallible beings, the concept seemed to make sense. The idea was that a medical resident would observe a procedure and then quickly perform the procedure. This would be soon followed by that same resident then teaching another resident how to perform the procedure.
Most patients would be horrified that some physicians still hold to this adage. They take a quick weekend stem cell course to observe a procedure and then go back to their practices with barely enough stem cell education to understand how the procedure works and then begin to try these procedures in real patients. After they have performed a few procedures, they then consider themselves expert enough to teach it.
Don’t believe it? I’ll give you a few examples from the stem cell world and how this approach can go bad…
Do One and Immediately Teach One
A few years back, I taught a novice physician how to perform simple procedures as part of a stem cell education course. I was satisfied that he knew enough to go back to his practice and begin carefully treating some patients. At the same time, I was also serving on the medical advisory committee for a conference. One of my jobs was to review applications submitted by physicians who wanted podium presentations at that conference. Much to my surprise, just a few weeks after the course, that same physician submitted a lecture as an expert on stem cells! I was appalled! How can you be an expert with just a few weeks of experience? I obviously told the conference organizers that this physician’s talk shouldn’t be allowed, as he wasn’t an expert but a novice, and as such he had no business teaching other physicians.
Do One—Mess It Up and then Mess Up a Patient
This year while teaching a stem cell education course here in Colorado for the Interventional Orthopedics Foundation, an older surgeon from overseas was in attendance. During the course, this student stood out as having absolutely no concept of how to guide a needle under guidance. As an orthopedic surgeon, he had obviously not done this before, and his technique was awful. Thankfully, this was a cadaver course, but as I counted up the number of injection-based injuries he was causing in these cadavers and realized that his technique never improved through the weekend despite major proctoring, I knew that I couldn’t, in good conscience, pass this guy. I felt awful but informed him in writing that he needed remedial education. He then went back to his home country and proceeded to try and replicate our more-advanced bone marrow aspiration technique (despite being told that I didn’t think that he was safe to perform these procedures). He somehow managed to place the trocar right through the pelvis bone into an unsuspecting patient’s abdominal cavity! Out of approximately 10,000 stem cell cases that we’re tracking for the Regenexx Network physicians, that had never happened! So this wasn’t a “stuff happens” complication, but actual medical malpractice.
Why would a physician who was told he wasn’t safe and didn’t have the procedural skills to perform these procedures proceed to do one anyway on a live patient? A healthy dose of “I am a surgeon, so I should have no problems with this” and “see one, do one, teach one.”
I’ve Never Done This Before, But How Hard Can It Be?
In April, just after giving a few lectures on stem cells at a conference, a physician approached me about whether we had treated many avascular necrosis patients with stem cells. I said that we had treated more than 200 through the years with good success if they were treated in the earlier phases of the disease. I asked him if he had ever treated a patient like this by using a long trocar (specialized needle) guided into the hip bone with fluoroscopy to inject stem cells. He said no, but he wanted me to give him some pointers on how to do it as he had just signed up with a company that was performing a clinical trial for a new biologic that was supposed to help bone healing, and they had asked him to use this technique to treat AVN hip patients! I was dumbfounded and asked him why he said yes to this company if he had never performed this high-risk needle-based procedure before? He confidently told me, “How hard can it be?”
The upshot? So as you can see, “see one, do one, teach one” is alive and well in medicine! While the practice has helped speed medical education, it’s thankfully been replaced in most medical schools with strict skills-based training. However, this is very much still alive and well in the orthopedic stem cell education world. How can we fix that? Structured coursework with cadaver-based training, testing, and assessment of physician skills (i.e., pass or fail). While this won’t protect all patients (see story above), at least it’s a start to make sure physicians get out of “see one, do one, teach one” mode. A great place that offers this type of rigorous and structured stem cell and PRP orthopedic training is the Interventional Orthopedics Foundation.