How could a blog post titled Learn how to think avoid my praise? This post made the Farnam Street Blog top 10 for 2015. The post refers to a wonderful essay, Solitude and Leadership By William Deresiewicz. On first reading (and this essay deserves several reads) 2 concepts resonated strongly.The first is, “Multitasking, in short, is not only not thinking, it impairs your ability to think. Thinking means concentrating on one thing long enough to develop an idea about it.”
We know that multitasking does not really work. This concept has great importance in medicine. We have added so many tasks to the patient interaction that the thought process can suffer. Our focus can get split often.
The second is, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea. By giving my brain a chance to make associations, draw connections, take me by surprise. And often even that idea doesn't turn out to be very good. I need time to think about it, too, to make mistakes and recognize them, to make false starts and correct them, to outlast my impulses, to defeat my desire to declare the job done and move on to the next thing.”
All too often we see diagnostic errors occur because we do not take the time to think. We substitute algorithms for thinking. Here are some recent examples:
1. Patient comes with a heart failure label. She has some basilar crackles. Her echocardiogram suggests diastolic dysfunction. Her discharge orders include daily furosemide. On readmission she has significant volume contraction, and a completely normal echocardiogram. Her cardiac exam is unremarkable. The instinct to treat crackles with a diuretic occurs because the physician involved did not take the time to think carefully about the patient's clinical presentation.
2. Almost every patient with hyponatremia gets immediate treatment with normal saline. Too often, physicians do not consider making a diagnosis until the treatment does not work.
3. The same situation occurs with elevated creatinine levels. Again some unknown algorithm tells many physicians to give saline without considering why the creatinine is elevated.
4. I have written about several patients with decreased bicarbonate. The instinct and first thought is that the patient has a metabolic acidosis, but sometimes the patient really is compensating for a respiratory alkalosis. Making the correct diagnosis requires that we take the time to understand what has happened to cause the lowered bicarbonate.
5. A patient gets admitted to our service with multiple vertebral fractures. A very good resident does not focus on a variety of laboratory abnormalities, because being “on call” is a multitasking nightmare. The patient was anemic and had a slightly elevated calcium. That should have triggered at the globulin gap. The total protein was greater than 10 and the albumin was approximately 3.5. Once the clues get presented, the likely diagnosis becomes very clear. Focusing on each laboratory test and trying to understand the abnormalities requires time.
For years I have written about the importance of taking time in medicine. Our payment system discourages thinking time, because we do not get paid for thinking. Our payment system is perfectly designed (albeit not consciously) to discourage thinking. And now the IOM has discovered diagnostic errors.
Excellent medicine requires thinking. We need to develop systems that give our physicians adequate time to think rather than to react. As Deresiewicz writes, “I find for myself that my first thought is never my best thought. My first thought is always someone else's; it's always what I've already heard about the subject, always the conventional wisdom. It's only by concentrating, sticking to the question, being patient, letting all the parts of my mind come into play, that I arrive at an original idea.”
Practicing medicine as a reactive activity results in cognitive errors. Very often we need to spend the time to concentrate on a clinical situation. Our patients deserve our focus.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.