Tuesday, March 24, 2015

From experienced clinician to master clinician

Dr. Gurpreet Dhaliwal, known by his colleagues as Goop, is regarded as one of the master clinicians in the department of Internal Medicine at UCSF. If you've attended very many SHM conferences you've probably been bedazzled watching him discuss a mystery case in CPC fashion.

How do you get to be a master clinician? Are some people just born that way? Goop has pondered this question and decided it's a matter of attitude and motivation as much as anything else. It's the subject of a talk he gave, which I was fortunate enough to attend, at the Society of Hospital Medicine national meeting last spring. That same talk, given as a guest medical grand rounds speaker at the University of Washington, is available for viewing here.

Goop tries to be evidence based in his talk but encounters a problem: there has been next to no research on this question in clinical medicine. In attempting to work around the problem Goop has to look to non medical fields, in which there is a fair body of research on what makes an expert. But such research tends to be unconvincing, as comparison of the art and science of medicine with the mechanics of industry falls short time after time. Fortunately though Goop sprinkles in plenty of personal insights he has gained on his journey to becoming a master clinician. I'll unpack a few things here that rang true to me although I recommend everyone watch the video in its entirety at the link above.

It's a lot about attitude.
Complacency is the enemy. The slide appearing about six minutes into the talk reflects the typical career learning curve. Early on the curve is steep. Everything is new and it's a struggle. After a while, though, things get easier. As experience accumulates we become comfortable and the curve flattens. This, according to Goop, is a zone of complacency where professional stagnation and eventual decline may ensue. The key to staying out of this rut is to keep the curve steep but it takes deliberate effort. If you're comfortable in a particular content area make it harder by inventing new challenges and go after them. Curiosity and humility, the realization of how little you know, are important drivers.

Practice must be deliberate.
Passive practice, the kind we get from seeing a lot of patients, is an inefficient learning method. Deliberate practice might mean, for example, making it a point to carefully review as many electrocardiograms (or rashes or images, etc) as possible during a given month along with related material in textbooks or review articles.

Make the most of case reports.
Though relegated to “low impact” status in medical journals, case reports can be powerful learning tools when read with deliberate learning objectives (not just casually). Case records and clinical problem solving exercises in the New England Journal of Medicine are but two examples.

Is this the next version of MOC? It's a lot of work but there is a key difference. Unlike MOC this is self motivated and self directed. And it's a much more robust form of learning than that which is imposed by some outsider who knows nothing of your educational needs.

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