#103: Train Your Brain: Mapping out your road to expertise

July 9, 2018 | By Matthew Watto, MD

Expert diagnostician, Dr. Gurpreet Dhaliwal, again joins The Curbsiders to dive deeper into the topic of clinical expertise.  Topics include, and are mainly focused on, Dr. Dhaliwal’s “training regimen:” feedback, simulation, quizzing, learning from consultants, and how to read the medical literature as a clinician.  While we found this episode to be incredibly useful (and entertaining to record), don’t let our bias sway your opinion! In fact, just listen to the episode for practical advise on how to improve your own clinical acumen.  

Dr Brigham’s comment:  Be forewarned, much of what we talk about is seemingly common sense, but, upon listening to the episode many times, I realize that we have, over time, overly complicated the fundamentals of expertise.  I’m just as guilty as the next physician.

Written and produced by:  Stuart Brigham MD
Hosts: Stuart Brigham MD, Paul Williams MD, Matthew Watto MD
Guest: Gurpreet Dhaliwal MD
Images by: Beth Garbitelli

Edited by:  Matthew Watto MD

Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Clinical Pearls:

1. Training for clinical expertise requires not just the experience, but deliberate practice and reflection.  You become an expert by having experience and reflecting on it.
2. Frank, honest peer feedback is necessary, but will only be received well if there is a “positive bank account” (five-to-one ratio between positive and negative feedback) between friends and not just transactional colleagues.  This also applies to your own personal relationships as well.
3. Knowing the “what” is important, but understanding the “why” helps you grow towards expertise
4. Simulation is necessary to put yourself in front of more cases than you otherwise would in clinical practice
5. Microquizzing, multimodal learning, and teaching help to consolidate new pearls of knowledge and wisdom

In-Depth Show Notes

Highlighted by “Quotations” (with a time stamp) to help you follow along.  You’re welcome!

“We owe it to ourselves and we owe it to our patients to get better.” (11:22)  The road to clinical expertise requires one to answer the most basic questions, “Why?”  We must be honest with ourselves and not overstate our own experience and understand the initial basic steps.

“We’re getting exposed to a ton of cases… and that is the best way of learning and developing expertise.” (12:05)  Many cognitive theories suggest that there is something else, but in order to get better in a certain domain, we have to purposefully encounter problems in that domain.  In other words, the more cases you encounter, the more likely you are to improve.

“The core series of cases are the ones that come before you.” (13:40)  Over time, encountering these cases will ultimately improve your clinical practice, but if you rely solely on your experience, you are unlikely to reach your maximum potential unless you put in additional effort.  Recommendations are fairly straight forward:

1. Patient Log:  Track cases and their outcomes through a patient log
2. Read on the margins:  Don’t treat all cases as “routine.”
3. Learn from colleagues:  Discuss clinical cases with colleagues

“It’s extremely effortful to track your patients.” (15:50)  While we talk a lot about keeping a patient log, it’s important to understand that this isn’t necessarily an easy task.  Many EMRs allow you to develop a patient list to help you track patients and this can be leveraged to help develop your own tracking method.  Recommendations for tracking include:

1. Random sampling:  Don’t just follow the complicated or questionable cases.  Consider including a few “routine” cases as well.
2. Reasonable number of patients:  Given the amount of effort required to track these patients, Dr. Dhaliwal is only able to track about 5% of the patients he sees in the inpatient or ER setting.
3. Resolution:  Follow the patient(s) until resolution (if reasonable) and/or consider following up with the team that took over your team to follow-up on the patients you cared for.  Was it osteomyelitis that you diagnosed? Did you miss a pulmonary embolism in that women on hormone replacement therapy? Be careful not to track too far out or, as Dr. Dhaliwal puts it, “your brain forgets the question you had”.
4. Requirements:  For all the discussion we have had on patient tracking, this does not include patients for whom you have the primary responsibility (i.e. as the primary care manager).

“Your brain can’t solve the problem if it’s trying to answer the wrong question.” (21:40)

“Hey, by the way, I have no reason to call you.  I’m just calling you to tell you you’re wrong.” (23:35)  Providing honest, frank peer feedback is necessary, but must be delivered gracefully.  However, “high functioning teams don’t hesitate to give negative feedback,” says Dr. Dhaliwal.  If we, in our healthcare team, find it difficult to give this feedback, it could be a reflection of the core team dynamics.  In other words, the team may be lacking the underlying positive, open environment necessary to accept difficult feedback.

“Five to one ratio turns out to be true in marriages as well.” (26:00)  The “five to one” ratio is necessary not just to build successful teams, but also relationships, including your personal ones.  Interestingly, while working on these show notes, I looked up the divorce rates for physicians and, surprisingly, they are some of the lowest.  However, knowing how physicians are thrust into professions that require them to learn leadership skills, this may not be as surprising.  Maybe physicians should be taking up leadership mantles more often…?  Sorry, back to your regularly scheduled show notes.

“I want to know the why… Sometimes it is hard to ask the why.” (28:58)  A colleague or consultant may feel like you are threatening them or challenging them, but these questions are important for our own learning.  Jokingly, it can work if you blame it on someone else (“…just so I can be clear when I explain it to my team, do you mind telling me why…”).

“…find a way to put yourself in front of more cases.” (34:30)  Simulating patient cases helps to go through the cognitive exercises and exposure to more cases than you would otherwise.  There are many different options, one of which this author has found useful is at http://www.humandx.org (full disclosure – they do not pay for advertising).  However, there are a myriad of options out there e.g. the NEJM case files.

“When the demand exceeds the supply of your neurons, that’s when learning happens.” (37:35)  Simulation (and any activity to exercise your brain) should feel difficult.  Clinical cases shouldn’t be easy and quizzing may be difficult.  This underscores the simple fact that learning is happening!  As Dr. Dhaliwal notes, “sweat in practice so you don’t bleed in the game.”

“You’re almost looking for excuses to draw on that thing you learned the first time.” (43:35)  In order to consolidate new data, you have to find new ways to get the brain to engage with new material, whether by quizzing, multimodal learning (…how about reading our show notes?), teaching others, or a myriad of methods.

“I don’t need to know all the articles, I just need to know about the articles.” (45:40)  One of the best ways to know about the articles is to read the secondary literature, essentially reading through the equivalent of the “Cliff’s Notes,” where someone who has better knowledge has read through the article(s), provided a summary, take-home points, and other important information.  Dr. Dhaliwal noted that he receives this from Journal Watch, First Watch, ACP Journalwise, etc.

“You become expert by having experience and reflecting on it.” (50:10)  

Take Home Points

1. Becoming an expert requires deliberate practice and hard work
2. Whether you become an expert or not is dependent on you
3. Learn to ask the tough questions, both of yourself and your colleagues

Goal: Listeners will gain an appreciation for the Clinical Reasoning process and the difficulties that underpin building expertise in medicine.

Learning objectives:
After listening to this episode listeners will…

1. Develop an appreciation for clinical expertise.
2. Recall the importance that deliberate practices plays in developing expertise
3. Develop a plan to improve their own clinical expertise
4. Identify the importance of teamwork and learning from their colleagues
5. Recognize that deliberate practice takes incredible effort

Disclosures: Dr Dhaliwal reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer, Intro
• 02:25 Guest Bio
• 03:57 Pun
• 04:25 Dr. Dhaliwal
• 05:57 Pick of the Week – Move, “Jiro Dreams of Sushi”
• 08:00 Pick of the Week – Podcast, “Unspooled”
• 09:06 Pick of the Week – Water Putty, “Durham’s Rock Hard Water Putty”
• 10:20 “Clinical Case” Introduction
• 12:00 Developing expertise, introduction
• 15:50 Developing a patient log
• 21:30 Asking the wrong question leads to the wrong answer
• 23:35 Telling a colleague they were wrong
• 26:00 Five to one ratio
• 28:58 Understanding the why
• 33:57 Simulation in practice
• 37:35 Quote on learning… Just listen.
• 41:00 Quizzing and consolidating memory
• 44:24 Reading the literature as a clinician
• 50:10 Bottom line
• 57:10 Outtro

Links from the show:

1. Jiro Dreams of Sushi
2. Unspooled Podcast with Paul Scheer and Amy Nicholson
3. Rock Hard Water Putty
4. Human Diagnosis (Daily cases to review)
5. NEJM Clinical Cases
6. NEJM Journal Watch
7. ACP JournalWise
8. Physician’s First Watch
9. Dhaliwal G. Premature Closure?  Not so fast. BMJ Qual Saf. 2017 Feb;26(2):87-89. doi: 10.1136/bmjqs-2016-005267. Epub 2016 Mar 15. https://www.ncbi.nlm.nih.gov/pubmed/26980778
10. Dhaliwal G. Inpatient Notes: Diagnostic Excellence Starts with an Incessant Watch. Annals of Internal Medicine. 2017 Oct;167(8):HO2-HO3. http://annals.org/aim/article-abstract/2657737/annals-hospitalists-inpatient-notes-diagnostic-excellence-starts-incessant-watch
11. Dhaliwal G. Going with your Gut. J Gen Intern Med. 2011 Feb;26(2):107-9. doi: 10.1007/s11606-010-1578-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3019336/
12. Dhaliwal G. Clinical Excellence: Make it a Habit. Acad Med. 2012 Nov;87(11):1473. doi: 10.1097/ACM.0b013e31826d68d9. https://www.ncbi.nlm.nih.gov/pubmed/23111262
13. Dhaliwal G. The Greatest Generation. JAMA. 2015 Dec 8;314(22):2353-4. doi: 10.1001/jama.2015.10622. https://jamanetwork.com/journals/jama/article-abstract/2474428?redirect=true