Tag Archives: medicine

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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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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