Our increased focus on diagnostic errors, while important, needs balance with a spotlight on expertise. Gary Klein in a wonderful book “Seeing What Others Don't“ teaches us that performance improves when we decrease errors AND increase insights.
Many physicians and especially clinician educators have focused on the reasons for diagnostic errors, but we rarely discuss the road towards expertise and insights. This blog post from one of my favorites, Farnam Street, addresses that problem, in “Becoming an Expert: The Elements of Success.”
This article has many important insights. One that I want to emphasize is the value of repetition in recognizing chunks. We have several situations in internal medicine that experts recognize and learners often do not. These concepts seem basic, yet too often we see a lack of understanding.
How do you interpret the vital signs? Seems simple and straightforward, yet learners often do not recognize the patterns. The CBC, the basic metabolic panel, the liver tests, EKGs, Chest X-rays, all of these seem routine and simple, yet experts view these tests in chunks and recognize patterns much more accurately.
As educators we need to first become experts on these fundamentals, and teach them every day. We have to understand the illness scripts for all the common diagnoses and the red flags that warn us that we might not have the seemingly obvious diagnosis.
Actually the mystery cases are not the causes of many errors, because we recruit assistance. When the patient has a complex presentation, we take more time, call more consults, and spend time searching the literature. But sometimes the presentation seems straightforward until we have enough experience to reconsider because something does not make sense. As I quoted recently from the BBC Series Sherlock, “You have a solution that you like, but you are choosing to ignore anything that you see that doesn't comply with it.” Experts have learned to not ignore clues.
It takes time and repetition to develop such expertise. If we want our learners to grow towards expertise, we must be discuss patients and their situations deliberately and completely.
Please read the Farnam Street article and carefully absorb the concepts. These writings are greatly influencing my teaching and learning.
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.