The Terrible Twos

I’m sorry to be the one to let you in on a horrible secret, but here goes: Medics around their second year are hitting the nadir of their medical skills and knowledge. They are commonly terrible paramedics and terrible employees. I guess there is never a never and never an always, but it certainly happened to me, and it is a normal finding to watch happen with other medics. Sorry – but that is just the way it is. 

I think the reason is that paramedic school sends you out into the world on the high point of a pendulum swing. A brand-new medic just spent between six months and two years studying their chosen craft. In addition, they are probably just finishing up their field internship, with irritable medics evaluating their every move. All the little EMS facts and medical knowledge are fresh and accessible in their brains, and they have been studying like mad for the National Registry test. 

Career roller coaster is a metaphor that works too. This is what my coaster looks like...
Picture source

Immediately after that, in many cases, they are hired into a paramedic service and begin a field training process. Once again a grouch is watching and nagging about their every move. Between calls, trainee paramedics are quizzed. Situations that trip them up are found and corrected. Trainees spend time studying protocols and medications. They are constantly asked: Why did you do that? What did you think was going on with that patient? 

The skill and knowledge pendulum is pushed higher.

Then a new paramedic clears the field training process, wherever they are, and begin to work as an independent medic. All that career pressure, going all the way back at least to the start of paramedic school, is suddenly relaxed. Now is when the skill/knowledge pendulum swings back to the suck end of the scale – but it takes a little time. There is no longer an irritable trainer looking for mistakes to hammer. A medic finds that they can palpate blood pressures, rather than auscultate, and in most cases nobody will call them out on it. Physical exams become progressively lazier until the point that they may even be skipped altogether. If-then statements fill their day, without thought or reasoning. General work habits slowly decline, patient and citizen complaints increase, and (being that they are progressively more comfortable with the experience of driving an ambulance fast) crashes and near-miss crashes start to occur. As the pendulum keeps swinging back away from the peak of skill that they had, the rate of patient non-transport calls increases. Unnecessary refusals increase. The new medic gets more bitter and acts like a burnout. 

Don't be sad, little medic.  It happens to everyone... Picture source

At least, this is a pattern that I commonly see. I will admit it happened for me. Mostly what is happening is that the pendulum overshoots the mean and falls to the below average end of the scale. A medic, especially in a busy system, has seen a lot of patients and begins to feel comfortable with their job. Ninety percent of patient presentations present no challenge to them. Unfortunately, these two-year medics think 100% of presentations present no challenge to their skills and knowledge. The gap between 90% and 100% is where problems arise.

I think it is related to the Dunning-Kruger Effect. This psychological finding is a failure of metacognition described by David Dunning and Justin Kruger in 1999.* What it describes is that relatively new or unskilled people experience “illusory superiority” and cannot correctly place their skill level into context. A person doesn’t know enough to accurately assess if they know enough. They don’t know enough about the scale to precisely place themselves on it. They don’t miss on the low side, though. Like an underheight middle schooler who thinks the NBA is in their future, the cognitive failure is to evaluate their skill level too highly. (On the other side, though, high skill individuals may underestimate their relative level of competence, thinking that tasks, which are easy for them, should be easy for others. But that is a topic for a later discussion.)

Looking back, I can completely see that I felt this way. I had two years in a high-volume system under my belt. I had run enough calls to get comfortable. I was good at my job, but I thought I was excellent at my job. I thought I was an incredible medic without even having to work at it. I was a prodigy medic, in my own head. I was lucky that I had a call or two that scared me without harming anyone. Looking stupid is better than causing harm. Even more beneficial to me was when I got to see a twenty-year medic work at full speed. Not work fast; work at their full speed. A salty old street dog doesn’t often feel the need to work as fast as he or she can – it only happens once or twice a year. Watching that, I went from feeling like I was a bad-assed über-medic to sitting in the captain’s chair with my mouth open, gobsmacked, wondering why I sucked so bad. 

Those near-miss calls and incredible partners were enough to wake me up and start the pendulum swinging back the other way, away from lazy and dumb. I’m glad that my poor skill level didn’t affect anyone else. 

For me, the pendulum swings got smaller and smaller, until it essentially stopped altogether. There wasn’t a whole lot of variability from day to day or week to week in my job performance. At this point, a great medic would push the pendulum to the skill end of its arc, and kept on pushing without letting it swing back to the lazy end. Keep pushing for excellence, not comfort. Reset the pendulum’s range. For the rest of their career, they would keep pushing to expand the length of the skilled side of the pendulum’s range.

*Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Personality Social Psych. 1999; 77(6): 1121-34.