“How do they do it?!!”
If you’re anything like me, you’ve probably found yourself asking that question after listening to a discussant on the podcast arrive at some unexpected diagnosis, only to have the biopsy or lab test prove them right. From the perspective of an early career learner, I find these acts of diagnostic prowess to be awe-inspiring, if not a bit intimidating. Were they simply born with superior brains? How did they get this good?
Dr.’s Vivek Murthy, Bridget O’Brien, and Gurpreet Dhaliwal sought to answer this question in a 2018 study. They interviewed 28 members of the University of California, San Francisco’s (UCSF) “Department of Medicine Council of Master Clinicians.” This is a peer-nominated group of academic clinicians renowned for their medical knowledge, teaching & communication skills, professionalism, and high-quality patient care. They conducted semi-structured interviews that focused on the participants’ early-career experiences and self-directed learning efforts.
From these conversations, they identified four general “themes”: (1) consistent learning efforts, (2) rigorous skills development, (3) developing “habits of the mind,” and (4) seeking out clinically rich working environments. Some specific activities mentioned by the participants included patient-directed reading (e.g., textbooks, case-reports, journal articles), efforts to track patient outcomes, moonlighting, and learning from their peers, among others.
What emerges from this discussion is a detailed description of years of hard work and dedication. These clinicians recount rigorous efforts directed towards improving their knowledge and clinical skills. Between the self-directed study and extra clinical opportunities they sought out, I can’t help but see parallels between these master clinicians and professional athletes. To achieve such mastery, they invest countless hours in training, or “working out,” their thinking.
Yet, it is worth noting that the master clinicians in this series had an average of 27 years in clinical practice (range, 13-50 years) at the time of these interviews. Today’s early career learners (myself included) might wonder how applicable the practices described in this study are to their own personal development efforts. Much has changed in the clinical work environment since these master clinicians were in training – work hour restrictions, the internet, electronic medical records, and the increasing medical complexity of our patients, just to name a few.
It could argued that today’s learners are entering the medical field at a time of unprecedented educational resources, and the implications for the development of clinical reasoning skills is awe-inspiring. Whereas the participants in the aforementioned study emphasized pursuing additional clinical opportunities, in part, to increase their case volume, learners today have a nearly unlimited reservoir of teaching cases available (although there is no true substitute for direct patient care). Clinical problem-solving cases are published and archived by a number of journals (e.g. NEJM, JHM, JGIM). With apps like the Human Dx project or twitter, trainees can read through a quick case on their way to work. Lastly, an increasing number of podcasts (the CPSers, CoreIM, and The Curbsiders) are changing the face of free and open access medical education, reaching learners as they jog or ride the bus.
So, the next time I hear a discussant on the podcast appear to miraculously solve a case, I’ll try to reframe my “awe” as “inspiration” – recognizing that with hard work and dedication, we too can eventually make such difficult diagnoses. It’s clear that clinical reasoning is a learned skill, one that can be honed by practicing cases, developing schemas, and expanding our medical knowledge. We at the CPSers recognize the growing interest in this field and will continue to work towards demystifying this learning process.
Now, if you’ll excuse me, I’ve got to get back to my morning clinical reasoning “work out”.