Deliberate practice in medicine: reflection

During our first semester of med school, when we had our class where we learned to interview patients, we had to write a journal entry after each encounter. It wasn’t due for a few days after class, so mine usually got written in the final minutes before the deadline. The first half, writing the patient history, was easy. Less easy was to come up with some deep thoughts about the patient encounter to fill up the final paragraph. Needless to say, it wasn’t my favorite exercise. It’s hard to force meaning into an encounter when you’re more focused on what questions to ask to fill up the silence.

Reflection gets used that way, and maybe it has it’s place, but reflection as a form of deliberate practice isn’t really about our growth as a person. This guide describes reflection in medical education as “experiential learning” and outlines the following steps in the process: 1. noticing what happened, whether through our own perceptions, feedback from others, or analysis of critical incidents; 2. processing, including learning needs and also the emotional content of a situation; and 3. developing a plan to meet learning needs. (The appendix includes some prompts.) Essentially, reflection as a tool is acting as your own coach.

One of my (multitude) of complaints about medical education is that the time to do this isn’t really built in. You’re either busy with patient care, or you’re not doing something clinical. The problem is it’s hard to remember the details of a situation after you’re not in the midst of it. I think in med school in particular there should be time blocked out so it doesn’t feel like an obligation: you could structure it so you see a clinic patients in the morning, and then have time blocked out to write both a note and also identify a learning need and do some reading. In residency, it’s harder, but as I’m going forward, I notice I do have down time during the day, which I usually use to do some combination of browsing the internet, practicing French vocab, and chatting. It’s much harder to make myself read, and when I do, it’s frequently random. So that’s a challenge to me, I guess…definitely room for improvement.

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What does deliberate practice look like in medicine?

The Olympics are over, but I was interested by this article on Mikaela Shiffrin–the 18-year-old who just became the youngest gold medalist in slalom. Basically unlike a lot of her cohort, who spend a lot of time and energy on entering races, she stayed at home and practice a lot, perfecting her technique. Less fun, probably, but obviously it paid off.

It reminded me a lot of Cal Newport‘s writing. I can’t remember when I discovered his blog, but I found some of his thoughts on specific study skills helpful in med school. More recently–now that he’s out of student-hood, I guess–he’s been writing a lot about the idea of mastery. Basically the idea is, to quote his book’s title, to become so good they can’t ignore you–to stop chasing a job based on what you think you’re excited about, and instead, to do the hard work at becoming excellent at what you are doing.

This resonates with me, I guess, because I took a few years off between college and med school. I wasn’t premed in college, but I did decide around graduation that it might be a good plan for me. In the interim, however, while finishing the prereqs and taking the MCATs, I took a job in a field related to my major. It was…fine. I mean, there were frustrations, but it wasn’t a bad job. And by the time I got around to leaving, I was getting better at it, and doing projects with more independence, and stuff. And so I think back, and wonder, if I’d just stayed there, how would things have turned out? A couple of my other young coworkers did, and are still there, and seem to be doing well. Maybe I should have been seeking mastery all along.

The grass is always greener, of course, and on the whole I’m glad I picked the path I did. But it did get me thinking about how to achieve mastery in medicine. What does it even mean, anyway? Being a clinician-scientist is easier to understand–it’s not really unlike being any other kind of scientist. But what if you just want to be a clinician? How do you get better at it?

I think there are two major components to being a good doctor. (Here I’m leaving out some of the other pieces, like running your office well so that patients aren’t kept waiting overly long, etc.) The first is mastery of a body of knowledge. We have some systems in place to help with this. They may not be ideal, but we have USMLEs and board exams and requirements for CMEs. The second is how you interact with patients–how you dress, your body language, how you phrase questions, how you listen, and show empathy, how you deal with a difficult patient, how you examine people. And I can tell you, from having watched a lot of physician-patient encounters, that most people need work in this area too. It gets de-emphasized, though, even if the powers that be try to test it on Step 2 CS.

So, deliberate practice. I don’t actually think a lot of what’s supposed to be practice works out that way. For one thing, when we admit a patient and write a note, we have talked about it with the attending already (usually), and so I’m writing down someone else’s plan. (Actually, frequently I’m writing my admission notes at the end of the day, and in an effort to get home at a reasonable time, I’m basically transcribing my resident’s note.) For another, a lot of the patient encounter becomes habitual, and like any other habit, we lapse into it unthinkingly, without looking for ways to improve.

So what are some ways to get to mastery in clinical medicine? I’ll be exploring that in more detail this week, but basically I think it requires 1. reflection; 2. thinking about how to handle a specific, commonly encountered situation; and 3. hypothesis testing. And, underlying them all, a commitment to improvement, something which is definitely lacking in many people.

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Topic Tuesdays: The Sochi Winter Olympics

There are so many awesome resources out there that this week is too easy. Some starting points: this NYTimes series; this NBC/NSF series of videos on the science behind Olympic sports (and the 2010 series and associated lesson plans). And movies: Cool Runnings, The Cutting Edge, The Mighty Ducks, Miracle.

1. Olympics history

How did the ancient Olympics start? Who were the athletes? What sports did they play? When and how did the modern Olympics start? Which Olympics have been cancelled, and why? Boycotted? What was the Munich massacre? What other Olympics have been impacted by terrorism?

2. A friendly competition

Pick a country to root for this Olympics. How have they done in the medal hunt in the past? How would you project them to do this year? Bet on who will do the best, adjusted for this. (Use real money to make it more exciting.) Research some of the country’s athletes competing this year, and write a profile or create a short video about one of them.

3. Playing host

How are Olympic venues chosen? Put together a proposal to host the Olympics in your town–how would you do it? (And inspiration.) Do host cities gain or lose by hosting the Olympics? Do you think it’s worth the cost?

4. How Olympic sports work

This NY Times series and the NBC videos give a jumping off point for exploring concepts in mechanics like speed, acceleration, friction, momentum, and angular momentum. How has the weather affected these Olympics? How do they ensure that there’s enough snow? How does snowmaking work?

5. Athletic training

How do you assess fitness? How do athletes from different sports train? What is VO2 max? Which sport burns the most calories? Try out an Olympic sport! What are performance enhancing drugs? How do they work? Do you think they should be banned?

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How does having kids affect your productivity?

Not much, if this Atlantic article is to be believed. Basically the researchers found that women with 2 or more kids were actually more productive, in terms of publications, than women with 1 kid or none. (The exception was right after having a baby, and also with preteens–all that angst, I guess.) This makes a certain amount of sense to me–economists seem like planners, on the whole, and women who are successful in that field most likely try to time their families to when is convenient–but it’s still nice to hear some validation that having kids doesn’t automatically make you a less than stellar worker.

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Teaching from textbooks

This Atlantic article isn’t a fan. I’m split on this. In general I think multidisciplinary learning centered around a topical theme engage students more than reading a textbook. The problem arises when there’s a certain body of knowledge that has to be mastered, for example to pass the USMLE. You just have to master a broad range of topics, and I think it can be hard to teach  that effectively without one. Plus, there’s something to be said for having a framework in which to put your existing knowledge. It’s easier to incorporate new facts when you have a skeleton on which to put them. Otherwise there’s a lot of randomness. The flip side of this is that when you have a survey that’s too broad, it also feels random–this was how I felt about introductory biology, for example: at one point you’re learning about organelles, then a neuron, then the heart’s chambers, and it doesn’t all feel like it ties together.

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Topic Tuesdays: African-American History and Civil Rights

So to flesh out what the new curriculum might look like in practice, welcome to the first Topic Tuesday, where I provide a theme as a jumping off point for learning. The core of the topic is a list of subheadings with questions. It’s not meant to be an exhaustive or complete list of things that should be known, nor are these learning objectives that should be memorized. It’s just a list of questions I think are interesting, what I’d like to learn more about myself, along with some ideas for projects, readings and media, and other resources.

For this week, we’ll be taking a look at two important and interrelated stories that have shaped our country: African-American history and civil rights. Both of these are topical this time of year, between Martin Luther King day and African-American History month.

What did I overlook? Let me know in the comments section!

Starting points:

1. Origins of the slave trade

Discovery questions: How did the slave trade originate in the Americas? How was it different from indentured servitude? How was it different from slavery in the Ancient World? What drove the demand for slaves? What parts of Africa did slaves come from, and what aspects of the political situation there facilitated the export of people? How were slaves transported to the New World?

Readings and resources:

2. The Institution of Slavery in the United States

Discovery questions: What was life like for slaves in the US? How were their freedoms limited? How did the US compare to other countries during this time?

Readings and resources:

3. The abolitionist movement and the Underground Railroad

Discovery questions: Describe the origins of the abolitionist movement. What was life like for free blacks? Escaped slaves? Research the life of Frederick Douglas. Read Uncle Tom’s Cabin – how did this book inspire the anti-slavery movement? How did it perpetuate stereotypes? What was the Underground Railroad?

Readings and resources:

4. The Civil War

Discovery questions: Was slavery the primary reason for the Civil War? What were some of the key sources of friction in the years leading up to war? What prompted Lincoln to issue the Emancipation Proclamation? How does the portrayal of the Civil War in Gone with the Wind correspond to real life?

Readings and resources:

5. Reconstruction and Jim Crow Era America

Discovery questions: What constitutional and legal changes were supposed to guarantee the rights of citizenship to African-Americans? What was life like for newly freed slaves? What legal, political and social/cultural mechanisms were used to keep them out of mainstream society and for intimidation?

Readings and resources:

6. The civil rights movement and integration

Discovery questions: What are civil rights? How are they protected by law? How did the civil rights movement start? Who were its leaders? What triggered the Montgomery bus boycott, and was it effective? Who was the Rev Dr Martin Luther King Jr, and what was the I Have a Dream speech? How was the American civil rights movement perceived by the rest of the world? Research the life and baseball career of Jackie Robinson. What was significant about Plessy v. Ferguson, Brown vs. Board of Education, and what were some of the struggles related to integrating schools?

Readings and resources:

7. Notable African American writers, musicians and other contributions to the arts and culture

Discovery questions: Read some of the below works of literature. How were the writers reflective of the time they lived in? How did jazz evolve? How does it differ from blues? Gospel? What are some of the subgenres? Listen to examples of each. Read about the life of Ray Charles.

Readings and resources:

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Evaluating job performance

The Atlantic takes on performance evaluations.

I’ve only had one “real” annual review–from before med school, when I worked for a consulting firm. There was a self-evaluation to fill out, and then I met with my boss, and he told me I was doing fine, which basically consisted of showing up on time and being enthusiastic. On the one hand, really, I was 23 and in an entry-level position. Still, it was not a terribly useful exercise except as a gateway to my 3% raise. Which is pretty much the vibe I get, from my husband and friends with corporate jobs, and from The Office.

In medical training, we instead get feedback. Both as a student and now in residency, we’re supposed to get some kind of feedback at the end of every rotation. This has also been somewhat hit or miss. For one thing, like the article suggests, people tend to think you’re doing a good job if they like you. This was most noticeable to me with certain male attendings who would banter about cars or what have you with my male counterparts, but it’s not a gender thing per say. Medicine tends to attract a lot of type A people who have strong interests and hobbies, and like to talk about them. I remember, for example, being stuck in a conversation between an attending and resident about Nantucket, and how things have changed over the years with all the new money buying up property. And let me just say that I had very little to add to that conversation.

Anyway feedback. So besides whether you bond with the person evaluating you, the other problem with medicine is most of how you spend your time is not observed. There is a move towards watching trainees interact with patients–some of my med school rotations had these index cards we had to get signed off, for example–and the good attendings and residents will let you do some of the talking. But for the most part, even as an intern, most of my H&Ps tend to be with me watching the resident do the interview, which I can guarantee doesn’t add much. So you get evaluated on what they can see–how you present a new patient, how you outline a plan, and, often, how you respond when pimped–which, for those of us who are less verbally agile spur of the moment, does not necessarily correspond to the extent of your medical knowledge.

Not that I’m complaining. I did well during my clinical rotations as a student, so I clearly wasn’t harmed by the whole thing. But neither have I felt like I’ve gotten much feedback that’s been helpful. What I’ve learned has mostly come from: i. from attendings who teach as they discuss the case; ii. from watching really good attendings and residents interact with patients; iii. from watching not very good attendings and residents interact with patients (ie what not to do); iv. from reading, conferences, and the like. Usually the constructive criticism I get falls under the category of “read more”, which is…not that helpful when you’re already tired and overworked. For one, frequently I got that feedback when I hadn’t encountered something yet in training–like starting my OBGYN rotation, when I was told that “I didn’t know as much as would be expected by this time in the year.” Contrast that to one helpful piece of advice as a student, when my resident told me to read the Step 1 and Step 2 review book topics that related to my patients.

What would be helpful? There are a lot of resources out there. Good feedback is frequent, immediately related to something that happened ie “teachable moments”, and gives suggestions for how to act differently next time. Basically, acting as a coach. Atul Gawande wrote a New Yorker article about getting someone to coach him once he’d finished training, as an attending. And that, in spades, is what feedback during medical training would ideally be. And, for that matter, for jobs in general.

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