Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
The NIH Clinical Center is the world's largest hospital totally
dedicated to investigational research and leads the global
effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
OUR SPEAKER IS DR. GURPREET
DHALIWAL, PROFESSOR OF MEDICINE
AT UNIVERSITY OF CALIFORNIA, SAN
FRANCISCO, DIRECTOR OF INTERNAL
MEDICINE STUDENT CLERKSHIPS SAN
FRANCISCO VETERANS AFFAIRS
MEMORIAL CENTER, A BACHELOR'S
DEGREE AT NORTHWESTERN AND
MEDICAL DEGREE IN 1994,
COMPLETED INTERNAL MEDICINE
RESIDENCY UNIVERSITY OF
CALIFORNIA, SAN FRANCISCO,
COMPLETED UCSF TEACHING SCHOLARS
PROGRAM, FOLLOWING THIS HE
JOINED THE UCSF FACULTY,
FOCUSING ON HOW DOCTORS DIAGNOSE
AND TEACH CLINICAL REASONING,
TEACHING IN A BROAD ARRAY OF
SETTINGS, ACADEMIC INTERESTS ARE
COGNITIVE PROCESSES AND
DIAGNOSTIC REASONING AND
CLINICAL PROBLEM SOLVING, STUDY
OF DIAGNOSTIC EXPERTISE.
CONSIDERED ONE OF THE MOST
SKILLFUL DIAGNOSE DIAGNOSING, E
MESMERIZES AUDIENCES MEANT TO
STUFF US.
THE "NEW YORK TIMES" SAID TO
OBSERVE HIM AT WORK IS LIKE
WATCHING STEVEN SPIELBERG TACKLE
A SCRIPT OR RORY MACKELROY A
GOLF COURSE, HE WAS PROFILED IN
AN ARTICLE AND WAS A WRITER FOR
"WALL STREET JOURNAL" A GUEST N
HIGHLY RATED PODCASTS, UCFS
DEPARTMENT OF MEDICINE COUNSEL
OF MASTER CLINICIANS, HAS WON
MUCH TEACHING AWARDS AND
PURPOSED MORE THAN 150 JOURNAL
ARTICLES, A VISITING PROFESSOR
ACROSS THE U.S., CHINA, JAPAN.
THIS IS THE POINT WHERE I PUT
DOWN THE SCRIPT AND TELL YOU HOW
DR. DHALIWAL CAME TO THE NIH.
I HAD A SPECTACULAR STUDENT WHO
BURNT OUT IN A TOP TEN MEDICAL
RESIDENCY.
AFTER BEING ON THE TREADMILL, SO
MANY RESIDENTS DO.
I COULD NOT INSPIRE THEM NO
MATTER WHAT I TRIED.
SUDDENLY, THEY PRESENTED WITH A
LASER FOCUSED MONO MANIA
RELATING TO ECSTASY OF MEDICINE.
I HAD TO ASK THEM IF THERE WAS
AN INFECTIOUS AGENT, THEY SAID
FIVE WORDS.
DR. DHALIWAL GAVE GRAND ROUNDS.
FAST FORWARD, A DIFFERENT FORMER
STUDENT NOW A RESIDENT AT UCSF,
PRESENTED WITH THE SAME INDUCED
MONO MANIA FOCUSED ON MEDICINE,
THIS TIME I RECOGNIZED THE
SYMPTOMS AND ASKED WHAT THE
INFECTIOUS AGENT WAS.
THEY SAID TWO WORDS.
DR. DHALIWAL.
THIS, MY CASE SERIES, IS BETTER
THAN A RANDOMIZED CONTROLLED
TRIAL.
YOU'RE ABOUT TO BE REMINDED WHY
YOU WENT TO MEDICAL SCHOOL AND
REDISCOVER THE MEANING IN
MEDICINE, WELCOME OUR SPEAKER,
DR. GURPREET DHALIWAL.
FROM SUPERFORECASTERS TO SUPER
DIAGNOSTICICIANS.
>>THANK YOU FOR
THE VERY KIND INTRODUCTION, ALL
OF IT WAS KIND.
IF THERE'S ANY PANDEMIC OR
MONOMANNIC ENDEMIC
I'LL BE ATTACHED TO THAT.
THINKING AND DIAGNOSIS AND
JUDGMENT, COMING FROM THE
PERSPECTIVE OF A TEACHER WHO
CARES ABOUT DIAGNOSIS AND TO
CONVINCE US WE SHOULD, DIAGNOSE
IS THE MOST IMPORTANT PROCEDURE
THAT WE DO IN MEDICINE, OUR
ENTRYWAY TO GETTING PEOPLE
BETTER.
AND IT'S REMARKABLE THAT DOCTORS
DO IT AS WELL AS WE DO BUT
THERE'S ALWAYS OPPORTUNITY FOR
IMPROVEMENT.
THERE'S A SAFETY DIMENSION, WE
HAVE TO GIVE PEOPLE THE RIGHT
LABEL ON WHAT AILS THEM TO GET
THEM BETTER.
HOUSEKEEPING SLIDES, OBJECTIVES,
DISCLOSURES.
THE ORIENTING FRAMEWORK FOR
TODAY'S TALK IS THIS EQUATION.
SO DIAGNOSIS WHEN YOU LOOK AT
HOW DOCTORS DO IT, WE DO IT
QUITE WELL, PROBABLY GET IT
RIGHT 85 TO 90% OF ENCOUNTERS
BUT THAT MEANS THERE'S ROOM FOR
IMPROVEMENT, INFLUENCED BY THIS
EQUATION THAT GARY KLEIN SHOWED
AT A MEETING, IF YOU'RE TRYING
TO IMPROVE PERFORMANCE THERE'S
TWO WAYS TO DO IT.
ONE IS THAT YOU CAN DECREASE
ERRORS, AND THE OTHER IS THAT
YOU CAN INCREASE EXPERTISE.
I WAS STRUCK BY IT BECAUSE THERE
ARE TWO SIDES TO THE SAME COIN
BUT THEY REQUIRE VERY DIFFERENT
APPROACHES.
IF YOU THINK OF MAYBE THE SPORTS
ANALOGY, DIFFERENCE BETWEEN
GREAT DEFENSE AND GREAT OFFENSE.
OR BETWEEN AVOIDING UNFORCED
ERRORS AND HITTING WINNERS.
AND DIALING DOWN ERRORS AND
DIALING UP EXPERTISE HAS THE
SAME ANALOGY.
SO IN THIS TALK, WHAT I'M GOING
TO DO IS SHARE A MENU OF
APPROACHES TO BECOMING A BETTER
DIAGNOSTICICIAN.
SOME ARE DRAWN FROM EXPERIENCE,
I PRESENT AS A MENU OF THINGS
THAT ANYONE AT ANY STAGE CAN
ADAPT IF WE'RE MOTIVATED BY THE
POSSIBILITY OF GOING FROM BEING
A GOOD DIAGNOSTICICIAN TO A
GREAT ONE.
DO THE MATH, WE'LL HIT THE
HIGHLIGHTS OF EACH ONE.
THE FIRST AND PERHAPS MOST
IMPORTANT FOR THE ASPIRES
DIAGNOSTICIAN IS TO GET YOURSELF
IN FRONT OF AS MANY STORIES AS
POSSIBLE.
WE'RE ACCUSTOMED TO LEARNING
THROUGH STUDIES AND TEXT BUT THE
UNIT OF LEARNING OF THE HUMAN
MIND IS BY STORIES.
IF YOU THINK ABOUT EVERY PATIENT
THAT WE TALK ABOUT WITH EACH
OTHER, IT HAS A STORY ELEMENT TO
IT.
EVERY PATIENT HAS A STORY.
AND THEY FOLLOW A PYRAMID, A
PLAYWRIGHT SAID ALL DRAMATIC
STORIES HAVE THIS ARC.
STORIES THEY SAY "ONCE UPON A
TIME THE PATIENT WAS IN THEIR
USUAL STATE OF HEALTH," AND
SOMETHING HAPPENS, LIKE THIS MAN
STARTED TO DEVELOP FEVER,
LYMPHADENOPATHY, THEY DID A
BIOPSY, NON-DIAGNOSTIC, A PET
SCAN SHOWED REGIONAL LYMPH NODES
IN THE NECK AND ARM, WASN'T
CLEAR WHAT WAS GOING ON.
EVERYONE WAS WORRIED ABOUT
LYMPHOMA SOMEONE TOOK A REAL
SOCIAL HISTORY AND FOUND --
FOUND THAT HE HAD JUST ACQUIRED
A NEW YOUNG KITTEN.
THAT LED THEM TO GET A
BARTONELLA SEROLOGY, POSITIVE,
TREATED WITH DOXYCYCLINE, GOT
BETTER, LIVED HAPPILY EVERY
AFTER AND WATCHED CAT MEMES ON
THE INTERNET INSTEAD.
WHEN WE LEARN A STORY LIKE THAT,
THE STORY OF CAT SCRATCH
DISEASE, IT IMPRINTS IN OUR
MIND.
THE BRAIN IS GOOD AT LEARNING
THROUGH STORIES, NOT SO GREAT AT
LEARNING THROUGH STUDIES OR
STATISTICS.
ONE OF THE ACTION STEPS TO
BECOMING A GREAT DIAGNOSE
-
DIAGNOSTICIAN, SOMEONE FIGURED
OUT THERE WAS A PET IN HIS LIFE,
THE STORY WON'T BE FORGOTTEN.
WHEN YOU LOOK AT STUDIES OF
EXPERTS IN OTHER FIELDS YOU FIND
THE WAY THEY REALLY TAKE
THEMSELVES FROM GOOD TO GREAT IS
ACCUMULATING AS MANY STORIES AS
POSSIBLE.
IN THE BOOK, MADE THE STICK, THE
HEATH BROTHERS TALK ABOUT
ACQUISITION AMONG COPY MACHINE
REPAIR MANUALS, THEY TAKE THE
SAME TESTS, BUT THE WAY THEY GET
BETTER IS THEY GET TOGETHER AND
SWAP STORIES.
YOU SHOULD MAKE NO MISTAKE, A
COPY MACHINE IS A WILDLY
COMPLICATED THING, CHEMICAL
ELEMENTS, ELECTRICAL AND
MECHANICAL ELEMENTS.
IN THE BOOK, WHAT THEY TALK
ABOUT IS THEY REALLY GET BETTER
BY SAYING HOW DID YOU APPROACH
THIS PROBLEM?
WHAT DID DO YOU WHEN YOU GOT
THIS ERROR MESSAGE?
THE WAY THEY ARE TALKING ABOUT
SOLVING THAT MACHINE SOUNDS
SIMILAR TO THE WAY WE GET
TOGETHER A CASE CONFERENCE OR
MORNING REPORT TO SOLVE THAT
SAME STORY.
AND THE POWER OF STORIES IS THAT
WHEN YOU ARE HEARING A STORY, IF
IT'S TOLD WELL, VIVIDLY ENOUGH,
YOU CAN ENVISION YOURSELF IN THE
SAME SITUATION, AND YOU CAN
ALMOST MENTALLY TEST OUT HOW I
WOULD HAVE HANDLED THAT
SITUATION.
AND IF IT'S DONE WELL, EITHER BY
THE STORY TELLER OR PERSON
ENGAGING IN IT, THE LINE BETWEEN
BEING IN THE AUDIENCE AND BEING
THE PROTAGONIST BLURS FOR
LONG-TERM MEMORY WHEN YOU NEED
TO CALL ON THAT MEMORY IN THE
FUTURE.
SO, FOR US IN MEDICINE, WE TAKE
CARE OF PATIENTS, THE CORE
FOUNDATION OF COURSE IS TO LEARN
FROM THE CASES THAT WE TAKE CARE
OF.
AND ENSURING ADEQUATE VOLUME IN
TRAINING AND CAREER IS A
FOUNDATION OF BEING A GREAT
DIAGNOSTICIAN.
IF WE WANT TO GO FROM GOOD TO
GREAT, NEXT STEP IS TO EXPAND
CASES.
IF I'M A TRAINEE, I TAKE CARE OF
MY OWN CASES.
DO I HAVE MY HEAD DOWN WHEN I'M
IN THE TEAM ROOM OR HEAD UP AND
LISTENING TO WHAT MY FELLOW
STUDENTS OR FELLOW RESIDENTS ARE
DOING AND LEARNING FROM THEIR
CASES AS WELL?
IF I'M NOT SATISFIED ENOUGH JUST
FROM LEARNING ABOUT ALL THE
CASES ON THE TEAM, CAN I FIND MY
WAY TO CONFERENCES, LIKE MORNING
REPORT OR M & M, OTHER CASES ARE
DISCUSSED AND I CAN UPLOAD MORE
CASES TO MY LONG-TERM MEMORY OR
DO I EVEN AVAIL MYSELF OF ALL
THE CASES THAT EXIST NOW.
USED TO BE IN THE PAST THEY WERE
IN JOURNALS, NOW ON TWITTER OR
PODCAST, AND INTERNET, AS WELL
AS TRADITIONAL JOURNALS, CASES
WHERE YOU CAN LEARN FROM ANOTHER
DOCTOR'S GREAT WORK AN INSIGHT
CRYSTALLIZED IN A SHORT WAY
OFTENTIMES.
IF YOU DO THIS RIGHT, ONCE YOU
GET ADDICTED TO THE LEARNING
THAT COMES FROM NOT ONLY YOUR
OWN CASES BUT HEARING FROM OTHER
CASES, YOU CAN SORT OF SLIDE TO
WHERE YOU ALMOST GET THE SENSE
OF FOMO, I MISSED A CONFERENCE,
TOOK A DAY OFF AND DIDN'T HEAR
WHAT MY CASES WERE GOING ON, I
HAVE TO CATCH UP AND FIND OUT.
YOU LEARN THE UNIT OF LEARNING
IS THE MOST POWERFUL OF ALL.
SO THE FIRST ACTION STEP FOR A
GREAT DIAGNOSTICIAN IS PUT
YOURSELF IN FRONT OF AS MANY
STORIES, NOT STUDIES, THAT YOU
CAN.
THE SECOND ACTION STEP, GIVE
YOURSELF STRETCH ASSIGNMENTS,
SOMETHING THE BUSINESS WORLD
USES FREQUENTLY.
WHAT THEY DO IS DELIBERATELY
PLACE A PERSON IN A CHALLENGING
SITUATION, SO THAT THEY HAVE TO
LEARN A LITTLE BIT MORE THAN
THEY KNOW CURRENTLY IN ORDER TO
FULFILL THE JOB.
I WAS REMINDED OF IMPORTANCE OF
THIS EARLY IN MY CAREER.
I MOONLIT AT A HOSPITAL IN AN
ADJACENT HOSPITAL, I LEARNED SO
MUCH, PART WAS NUMBER OF CASES,
PART WAS HABITS LIKE TRACKING
PATIENT OUTCOMES, PART WAS I WAS
PUSHED OUT OF MY COMFORT ZONE.
I WOULD BE ASKED FOR INSTANCE TO
ADMIT A PEDIATRIC PATIENT WHO
WAS 16 WITH PANCREATITIS EVEN
THOUGH I'M AN INTERNIST, OR
ASKED TO TAKE CARE OF A WOMAN IN
LATE PREGNANCY WITH ASTHMA
EXACERBATION OR GI BLEEDING OR
INTRACRANIAL BLEEDING, WAS LEFT
FOR ME TO MANAGE ALONE.
I WAS LEFT WITH DISCOMFORT BUT
HAD A WHOLE LOT OF GROWTH.
A HOSPITALIST HERE DID A STUDY
OF COUNCIL OF MASTER CLINICIANS
AND FOUND THE SAME STORY, MANY
TOOK ON STRETCH ASSIGNMENTS
EARLY IN THEIR CAREERS, WAY
BEFORE THEY WOUND UP BECOMING
MASTER CLINICIANS.
HERE ARE SOME QUOTES THAT SOME
TOLD THEM.
STORIES ABOUT WORKING WHERE
VOLUME WAS HIGH, AND WORKING AS
HARD AS THEY COULD BUT LEARNING
AS THEY WENT ALONG.
BEING THE ONLY DOCTOR
RESPONSIBLE FOR A CADRE OF
PATIENTS, DIFFERENT FROM THE
SAFETY OF EITHER MEDICAL CENTER
OR THEIR PRIVATE PRACTICE.
AND JUST FRAMING THE WHOLE
EXPERIENCE AS BEING INTENSE
LEARNING BUT EMPHASIZING THE
LEARNING PART OF IT.
BECAUSE I HAVE TO SAY WHEN MANY
OF US KNOW WHAT WE'RE
CREDENTIALS TO TAKE CARE OF, OR
IN OUR OWN MIND UNDERSTAND
LIMITS, IT'S EASY TO SAY THERE'S
PATIENTS I CAN AND CAN'T TAKE
CARE OF.
BUT THERE'S A SUBSET OF PATIENTS
RIGHT ON THE MARGIN.
AND YOU MAY WORRY ABOUT, WELL,
EITHER BY LEGALLY OR
CREDENTIALING OR MY COMFORT
SHOULD I TAKE CARE OF THIS
PATIENT?
I WANT TO ENCOURAGE YOU TO ALSO
WORRY ABOUT THE MISLEARNING THAT
MIGHT HAPPEN IF WE NEVER VENTURE
OUT OF OUR COMFORT ZONE.
IF YOU FIND YOURSELF ON THE
MARGIN WHERE THE PATIENT
SLIGHTLY FURTHER ON THAN YOU'VE
TAKEN CARE OF, TRY TO THINK
ABOUT ENGAGING THIS AND SAY, YES
I'LL TAKE THIS PATIENT.
SWIPE RIGHT NOT LEFT ON THE
PATIENT WHEN THAT OPTION IS
RIGHT THERE IN FRONT OF YOU
BECAUSE WHEN YOU SAY YES, I CAN
DO IT, THE ODDS ARE THAT YOU
CAN.
AND THAT YOU'LL LEARN AND THE
PATIENT WILL BENEFIT FROM
SOMEONE SO DEDICATED TO LEARNING
AT THE SAME TIME.
SECOND ACTION STEP FOR
DIAGNOSTIC EXPERTISE MOVE FROM
COMFORT ZONE TO LEARNING ZONE
AND STAY AT THAT MARGIN.
NOW, ONE OF THE THINGS THAT
MOTIVATED ME TO GET IN THIS
FIELD ALTOGETHER IS ROLE MODELS.
EXCELLENT CLINICIANS WHO I
WATCHED AND ADMIRED DIAGNOSTIC
SKILL.
SOME WERE IN MY RESIDENCY, AMONG
MY COLLEAGUES, BUT YOU FIND
GREAT DIAGNOSTICIANS IN ALL
CORNERS IF YOU LOOK AROUND.
ONE OF MY FAVORITE ARE THE TWO
HERE.
YOU MAY OR MAY NOT RECOGNIZE
THESE TWO DIAGNOSTICIANS, THEY
ARE GENERALISTS, IF THEY HAVE
BEEN IN PRACTICE FOR 40 YEARS,
THEY CAN SOLVE MULTIPLE CASES
PER HOUR, BUT IF YOU TAKE A LOOK
AT THEIR OFFICE YOU MAY GET A
SENSE OF WHO I'M TALKING ABOUT.
THIS IS THE TAPPER BROTHERS, ON
NATIONAL PUBLIC RADIO TOOK CARE
OF VIRTUALLY EVERY CAR MALADY
YOU CAN IMAGINE THAT CAME
THROUGH THE DOOR.
THEY WORK IN TEAMS.
THEY LOVE THEIR JOBS.
WHEN YOU LISTEN CAREFULLY YOU
SEE THAT THEY CARE MORE ABOUT
THE PERSON THAN THEY DO ABOUT
THE CAR.
BUT ONE OF THE THINGS FROM AN
EXPERT DIAGNOSTICIAN STANDPOINT
THEY DID SO WELL IS THEY WENT
BACK AND CHECKED THEIR WORK.
SO JUST LIKE DIAGNOSTICIANS,
THEY READ DIAGNOSES BUT HAD A
FEATURE, STUMP THE CHUMP, ASKED
PREVIOUS ASKED HOW WAS OUR
ADVICE?
WE BASICALLY MAKING
PROGNOSTICATIONS AND GUESSES,
AND WE HAVE TO FIND OUT HOW THE
STORY ENDS.
THAT'S EXACTLY WHAT THEY DID.
THEY WOULD GIVE SIMPLE ADVICE,
DID YOU REPLACE THE BRAKES LIKE
WE ASKED?
DID THE MOTOR START RUNNING
BETTER WHEN YOU SWAPPED OUT THE
SPARK PLUGS?
EVEN IF THEY GAVE LIFE ADVICE,
DID YOU DUMP THAT USELESS
BOYFRIEND LIKE WE TOLD YOU TO?
THEY WANTED TO KNOW HOW THE
ADVICE WENT AND PUT THEIR ADVICE
THERE AND SCORE FOR EVERYONE TO
SEE.
IT WASN'T PERFECT BUT IT'S AN
AWESOME DISPLAY OF A COMMITMENT
TO LEARNING BY TRACKING YOUR OWN
WORK.
IF YOU GO BACK TO THE STUDY OF
MASTER CLINICIANS THAT I
MENTIONED, BY DR. MURTHY, THAT'S
WHAT HE FOUND IN HIS STUDY AS
WELL.
HERE IS A CASE OF SOMEONE WHO
DESCRIBES SEEING A PATIENT WHERE
WAS THOUGHT TO HAVE A BONE
MARROW DISORDER AND DIED.
AND ON AUTOPSY, THEY HAD AN
AUTOPSY, WHICH WAS A GIFT OF THE
FAMILY, TO THE DOCTORS AT THE
TIME, BUT THERE WAS NO EVIDENCE
OF THE MALIGNANCY THEY FOUND.
INSTEAD, WHAT THEY FOUND, THERE
WAS AS PERGILLUS, A PERVASIVE
FUNGUS.
IT'S NOT JUST THE MEDICAL
LEARNING THAT IT CAN MIMIC
HEMATOLOGIC MALIGNANCY, THAT'S
IMPORTANT, BUT THE THING I WANT
TO EMPHASIZE IS INSIGHT OF THE
PERSON TELLING THE STORY WHO
CONCLUDED THIS BY SAYING WE CAME
PRETTY CLOSE TO NOT LEARNING
FROM THAT CASE.
I WANT TO EMPHASIZE AGAIN WE
CAME PRETTY CLOSE TO NOT
LEARNING FROM THAT CASE, WHICH
UNDERSCORES THERE'S SO MANY
TIMES WE'RE ADJACENT TO LEARNING
BUT IF WE COULD MAKE ONE EXTRA
STEP WE COULD UPDATE OUR
KNOWLEDGE AND INSIGHTS THAT
WE'RE SO CLOSE TO GETTING BUT
TAKES A LITTLE BIT OF EFFORT.
IF YOU STUDY OUR PRACTICE OF
MEDICINE, IT'S HIGH IN
DECISIONS.
HAS A HIGH DECISION DENSITY,
DECISIONS MADE PER UNIT TIME.
BUT QUITE OFTEN, WE OPERATE IN
AN OPEN LOOP SYSTEM.
SO WE GIVE INPUT, DECISION IS
MADE, THERE'S AN OUTCOME.
BUT THE OUTCOME MIGHT NOT BE
KNOWN TO US.
I MAY GIVE A PATIENT ON THE
PHONE OR THEY ARE TAKEN CARE OF
BY ANOTHER PERSON, OR I'M IN THE
ICU AND THE PATIENT IS SENT BACK
TO THE WORD.
NO BIOLOGICAL OR INDUSTRIAL OR
COGNITIVE SYSTEM THAT DOESN'T
IMPROVE BY FEEDBACK.
WE OPERATE IN AN OPEN LOOP
SYSTEM.
WITH A TRACKING SYSTEM YOU FIND
OUT HOW THE STORY ENDED WITH MY
PATIENT.
IF WE DON'T DO THIS, THIS IS THE
CHALLENGE, THAT I CAN GO ON NOT
FINDING OUT THE STORY OF MY
PATIENTS.
I CAN GIVE PROGNOSTICATIONS,
JUDGMENTS, MOVE THEM ALONG IN
THE HEALTH CARE SYSTEM.
BUT IF I LOSE TRACK, WHAT
HAPPENS IS I'M BUILDING MY
CONFIDENCE IN MYSELF BUT I'M NOT
NECESSARILY BUILDING MY
COMPETENCE.
SO WORKING WITHOUT FEEDBACK
BUILDS YOUR CONFIDENCE BUT
DOESN'T BUILD YOUR COMPETENCE.
YOU HAVE TO BUILD A TRACKING
SYSTEM, LOW TECH BY PAPER AND
POST--IT NOTES OR HIGH TECH.
IMPROVE THE JUDGMENT AND
CALIBRATION OF THE MIND.
IT HAS TO KNOW HOW THE STORY
ENDS.
OSLER, REFLECTING ON THIS TRAIT
OVER A CENTURY AGO SAID, HAVE
MERCY AND CONSIDERATION FOR THE
OTHER PERSON, BUT NONE FOR
YOURSELF AS A CLINICIAN, OVER
WHOM YOU MUST KEEP AN INCESSANT
WATCH.
I WANT TO EMPHASIZE THAT POINT
ABOUT INCESSANT WATCH, IT IS A
HUMBLING BUT REALLY PRODUCTIVE
WAY TO GIVE YOU THE BEST FORM OF
CME AROUND IF YOU CAN TRACK YOUR
PATIENTS AND FIND OUT HOW THE
STORY ENDS BECAUSE IT UPDATES
YOUR MENTAL MODEL FOR THE NEXT
TIME IT SEES THAT SAME PATIENT.
DOCTORS WHO FOUND ASPERGILUS
UPDATED THEIR MODEL, AND WE
SHOULD ALL HOPE FOR THAT BECAUSE
ALL OF OUR PATIENTS DESERVE US
TO LEARN FROM THEIR PAST
EXPERIENCES.
NOW, THE FOUNDATION OF
REASONING, MUCH INK HAS BEEN
SKILLED HOW TO BE A BETTER
SPEAKER OTHER REASONER BUT YOU
HAVE TO HAVE A MASSIVE AMOUNT OF
KNOWLEDGE.
SOMETIMES THERE'S A MISTAKE
THAT'S MADE BY SAYING IN AGE OF
INTERNET YOU DON'T HAVE TO
MEMORIZE THINGS BECAUSE
EVERYTHING IS ACCESSIBLE.
BUT THAT'S NOT TRUE AT ALL.
JUST BECAUSE I HAVE ACCESS TO A
GERMAN DICTIONARY DOESN'T MEAN
I'M FLUENT IN GERMANY.
HAVING ACCESS TO KNOWLEDGE IS
NOT THE SAME AS KNOWING HOW TO
ACTIVATE, DEPLOY, APPLY IT.
SO WE SPEND MUCH OF OUR CAREERS,
IN FACT YOU CAN DESCRIBE THE
ENTIRE ARC OF OUR CAREER,
BUILDING MORE AND MORE
KNOWLEDGE.
YOU NEED IT.
CAN YOU NOT REASON YOUR WAY INTO
A DIAGNOSIS LIKE MYASTHENIA
GRAVIS UNLESS YOU HEARD ABOUT IT
AND KNOW IT AND UNDERSTAND ABOUT
IT.
BUT THERE'S AN INTERESTING
PHENOMENON THAT CAN HAPPEN WHICH
YOU CAN GET TO THE POINT OF
DIMINISHING RETURNS.
WE CONTINUE TO PACK MORE AND
MORE KNOWLEDGE INTO OUR BRAINS,
TO THE BEST OF OUR KNOWLEDGE
LONG-TERM MEMORY DOESN'T HAVE A
STORAGE LIMIT.
BUT THERE IS A PROBLEM WHEN WE
SPEND ALL OUR TIME LEARNING
STUFF AND FORGET TO PRUNE THE
INFORMATION WE HAVE AND FAIL TO
ACT IN UNLEARNING.
SO REMEMBER THAT THE DIAGNOSTIC
PROCESS IS A JUDGMENT.
THAT JUDGMENT IS INFORMED BY THE
KNOWLEDGE THAT WE POSSESS OR
READ ABOUT OR LOOK UP.
BUT MANY THINGS GET PERPETUATED
YEAR AFTER YEAR, GENERATION
AFTER GENERATION, AND THEY CAN
CONTAMINATE OUR THINKING BECAUSE
THEY ARE FAKE NEWS, FALSE
KNOWLEDGE, THINGS THAT GET
PASSED ON AS MYTHS.
THERE ARE MANY.
SOME ARE CONTROVERSIAL.
SOME ARE HELD BY ONE GROUP OR
THE OTHER.
BUT WE HAVE TO BE AWARE OF
SOMETIMES WHEN WE'RE CARRYING
THINGS FORWARD THAT ACTUALLY ARE
HARMING OUR PATIENTS RATHER THAN
HELPING THEM.
YOU KNOW, THERE'S DEBATES ABOUT
WHETHER IV CONTRAST CAUSES RENAL
INJURY WHICH WE'VE HELD AS AN
AXIOM BUT SO MUCH SHOWS THAT'S
NOT THE CASE.
OR YOU LEARN SOMETHING LIKE IF
YOU MIX ALCOHOL AND FLAGELA, YOU
GET A SULPHUR REACTION, THEY ARE
A DISSERVICE IF WE CARRY THEM
FORWARD.
IT'S SUPER HARD TO UNLEARN WHAT
YOU HAVE LEARNED.
IT'S NOT NATURAL.
ONCE THE NEURONS WIRE TOGETHER
THEY FIRE TOGETHER, AND IT'S
VERY HARD TO DISENTANGLE THEM.
SO I THINK IN A GENTLE WAY I'M
TRYING TO SAY THIS IS SOMETHING
YOU HAVE TO TRY REALLY HARD TO
DO, NOT JUST LEARNING BUT
UNLEARNING SOME OF THE THINGS
WE'VE BRING TO THE DIAGNOSTIC
PROCESS THAT ARE FAKE NEWS OR
OUTDATED INFORMATION.
BUT AS MUCH AS I MIGHT TRY IT IN
A GENTLE WAY, SOMETIMES WE HAVE
TO HAVE A MORE FORCEFUL TEACHER
TO TELL US THIS IS WAIT TO
IMPROVE DIAGNOSTIC THINKING.
WHILE I MAY HAVE SOME HEFT AT MY
AGE, THE HELP OF A 900-YEAR-OLD
TEACHER MAY DRIVE THIS POINT
HOME.
>>WE'LL NEVER GET IT OUT NOW.
>>SO CERTAIN ARE YOU.
ALWAYS WHAT YOU WOULD CONNECT BE
DIFFERENT.
HEAR YOU NOTHING THAT I SAY?
>>MASTER MOVING STONES IS ONE
THING, THIS IS TOTALLY
DIFFERENT.
>>NO, NO DIFFERENT.
ONLY DIFFERENT IN YOUR MIND.
YOU MUST UNLEARN WHAT YOU HAVE
LEARNED.
>>ALL RIGHT.
I'LL GIVE IT A TRY.
>>NO.
TRY NOT.
DO.
OR DO NOT.
THERE IS NO "TRY."
>>YODA IS STERN BUT HE'S GOT A
POINT WHICH IS THAT IT'S SO HARD
THAT YOU HAVE TO MAKE A
COMMITMENT TO DOING IT.
SO THE ACTION STEP FOR US AS WE
MOVE FORWARD TO CONTINUE TO
LEARN, PAY ATTENTION TO THE
LATEST AND GREATEST, BUT WE ALSO
HAVE TO PAY ATTENTION TO THE
AUTHORS AND SCIENTISTS WHO GO
BACK AND REEXAMINE WHAT WE ONCE
BELIEVED.
PAY ATTENTION TO THE MYTH
BUSTERS THAT YOU HEAR ABOUT.
WHETHER YOU CALL IT UNLEARN OR
TAKE THE MORE GENTLE "LET IT GO"
RECOGNIZE THAT SKILL IS AS
IMPORTANT AS ACRETING MORE
KNOWLEDGE.
WE HAVE TO BING BRING THE BESTT
OUTDATED KNOWLEDGE.
ONE THING I LOVE ABOUT WORKING
AT THE V.A. HOSPITAL, I HEAR
PATIENTS FROM STORIES, RICH
LIVES THEY CARE, BUT THE STORY
IS OFTEN THE CLUE.
I FOR TOO LONG OVERLOOKED THAT.
SOMETIMES THE ANSWER IS IN THE
STORIES THE PATIENT HAS TO TELL,
IN THE SIMPLEST WAY.
I WAS REMINDED OF THIS A WHILE
BACK WHEN TAKING CARE OF A
PATIENT IN THE EMERGENCY ROOM, I
WORKED IN THE EMERGENCY ROOM AND
URGENT CARE, IN THE HOSPITAL AND
GENERAL MEDICAL CLINIC, ALL THE
SETTINGS, I LOVE THAT
OPPORTUNITY AS A GENERALIST.
IN URGENT CARE THE PATIENT'S
LEFT ARM WAS HURTING AND HE HAD
A RASH ON HIS LEGS.
IF YOU SPEND ENOUGH TIME IN
URGENT CARE YOU KNOW
MUSCULOSKELETAL COMPLAINTS AND
SKIN CONDITIONS ARE DESTINED
OFTEN TO GET A NON-SPECIFIC
LABEL FROM US.
I ANTICIPATED THAT'S WHERE I
MIGHT GO.
BUT I ASKED HOW THINGS WERE
GOING IN LIFE.
WHAT ELSE HE WAS DOING.
HE HAD THE NON-SPECIFIC ACHE
THAT I COULDN'T LOCALIZE.
I GOT TO TALKING ABOUT HIS LIFE.
HE'S A MOUNTAIN MAN, NORTHERN
CALIFORNIA, ISOLATED AREA,
BUILDING A SHED IN THE SNOW
ESSENTIALLY AT THIS TIME OF
YEAR.
HE WAS PUTTING UP CAULKING, PUT
THE WALKING TRAY ON HIS ARM, HE
HAD BEEN HOLDING IT FOR HOURS ON
END.
BY HIM TELLING ME THAT, I SAID,
I THINK I KNOW WHY YOUR FOREARM
IS HURTING.
I WAS PUTTING MASSIVE WEIGHT ON
IT, THAT WAS EASY.
WE TURNED TO THE RASH.
RASHES OFTENTIMES ARE THE TYPE
OF THING DOCTORS ARE LIKE, BOY,
IF I CAN'T GIVE AN
ANTI-INFECTIVE AGENT OR STEROID
AGENT I DON'T KNOW IF I'M GOING
TO MAKE PROGRESS AND THIS IS
WHAT I FELT LIKE WHEN HE ROLLED
UP HIS PANTS AND SHOWED ME
RASHES ON BOTH LEGS, SHINS TO
THE ANKLES, A LITTLE ON THE
FEET.
LIKE SMALL DOTS.
I LOOKED AND SAID HE DOESN'T
LOOK SICK, LIKE VASCULITIS.
DIDN'T LOOK LIKE CELLULITIS,
WASN'T A FUNGAL INFECTION.
I'M IN A BIND HERE, I DON'T KNOW
WHAT I'M GOING TO DO.
WITH A LITTLE BIT OF TIME I SAID
TELL ME MORE ABOUT WHAT'S BEEN
GOING ON WITH THAT WOOD SHED
YOU'VE BEEN BUILDING OUT BACK IN
THE SNOW.
OH, WELL, IT'S GREAT, I LOVE IT.
I TOLD YOU ABOUT THE CAULKING
BUT IT'S FREEZING COLD, BUT THE
GOOD NEWS IS I WENT TO COSTCO
AND GOT THESE SOCKS, WINTER
SOCKS, THEY ARE TERRIFIC!
WINTER SOCKS?
TELL ME ABOUT THOSE SOCKS.
AS HE TOLD ME MORE ABOUT THE
SOCKS, NOT GREAT DETAIL, BUT HE
BOUGHT THEM ABOUT TWO WEEKS AGO.
WHEN DID YOUR RASH START?
TWO WEEKS AGO.
EXACTLY MATCHED OF THE NYLON
LINING OF WHERE HIS RASH WAS.
THE NYLON THREADS AT THE TOP
WERE AN EXACT MATCH.
I RECOGNIZED NOT FROM YEARS OF
MEDICAL TRAINING BUT JUST COMMON
SENSE, HEARING THE STORY, HE HAD
A CONTACT DERMATITIS.
I GAVE HIM STEROIDS, WHICH I
WOULD HAVE DONE ANYWAY, BUT I
KNEW THE DIAGNOSIS IN THIS CASE.
THIS AND MANY OTHER STORIES AND
EXPERIENCES REMINDED ME THAT
SOMETIMES WE THINK ASKING PEOPLE
ABOUT THEIR LIFE IS LIKE SMALL
TALK, OR JUST RAPPORT BUILDING,
AND IT IS, HUMANIZING THE
RELATIONSHIP, I'LL ALLUDE IN A
MINUTE, BUT IT'S OFTENTIMES AN
ENTRY WAY TO RICH DIAGNOSTIC
INFORMATION.
ONE OF THE WAYS TO HABITUATE IS
UNLEARN SOMETHING MANY OF US GET
TAUGHT, THAT A SOCIAL HISTORY IS
WHAT DO YOU WHEN YOU SMOKE,
DRINK, USE DRUGS.
ALMOST EVERYONE IN THE ROOM HAS
GONE THROUGH TRAINING, THIS IS A
SOCIAL HISTORY, BUT NOT ONLY IS
IT IMPOVERISHED, THERE'S TONS OF
CASES WHERE THIS DOESN'T MATTER,
IT'S NOT A GREAT USE OF THE WORD
"SOCIAL," WHEN WE TALK ABOUT
SOCIAL JUSTICE, SOCIAL
DETERMINANTS OF HEALTH, ME MEAN
IT TO REFER TO THE WORLD AROUND
US.
THIS SORT OF PHYSICIAN-CENTERED
SOCIAL HISTORY JUST GETS AT
THREE BEHAVIORS THAT MAY SOLVE
SOME CASES AND ARE IMPORTANT IN
OTHERS BUT HARDLY PORTRAY THE
SOCIAL WORLD OF THE PATIENT.
THE ACTION STEP TO GET BETTER,
NOT JUST FOR RAPPORT BUILDING
BUT ALSO FOR TRUST BUILDING AND
DIAGNOSTIC INFORMATION BECAUSE
IT'S OFTEN THERE, GETTING A TRUE
SOCIAL HISTORY.
HOW DO YOU START YOUR TYPICAL
DAY, WHO IS IN YOUR WORLD, TELL
ME MORE.
AT THE V.A. HOSPITAL THAT
INVOLVES TAKING A MILITARY
HISTORY, WHAT BRANCH YOU WERE
IN, WHAT DID YOU DO.
AND IT IS MORE THAN JUST
BUILDING RAPPORT, I WANT TO SAY
THAT'S MAYBE ONE OF THE BEST
EFFECTS, OFTENTIMES THE MOST
IMPORTANT INFORMATION IS THERE.
NOW, WE ARE BUSY IN PRACTICE,
IT'S HARD TO REMEMBER TO DO
THIS.
ONE OF THE THINGS WE'VE DONE IN
OUR TEACHING CONFERENCES, HARD
WIRE THIS ACTIVITY, TO CARVE OUT
THE SOCIAL HISTORY AND USE IT AS
A PATIENT-CENTERED BOX RATHER
THAN DOCTOR-CENTERED BOX.
WHEN WE PRESENT DATASETS LIKE IN
MORNING REPORT CONFERENCE WE DO
HAVE ALL THE HEALTH-RELATED
BEHAVIORS BUT EXTEND THEM BEYOND
THE THREE, NOT JUST SMOKING,
DRINKING, DRUGS.
NUTRITION, EXERCISE, SEXUAL
ACTIVITY, ALL OF THOSE HAVE
IMPLICATIONS FOR HEALTH, A GOOD
INVENTORY ASKS ABOUT IT.
WHAT WE HAVE AS A SEPARATE BOX
FOR SOCIAL HISTORY, AND IF I'M
PRESENTING A PATIENT OR WRITING
A NOTE, REALIZE I DON'T HAVE
ANYTHING TO PUT IN THERE, THEN I
REALIZE I REALLY DON'T KNOW THE
PATIENT AT ALL.
I'VE TREATED HIM AS A BIOMEDICAL
ENTITY AND DATASET.
AND THE REAL HUMAN CONNECTION OR
OPPORTUNITY TO KNOW THEM AS A
PERSON AND PERHAPS GET
DIAGNOSTICALLY RICH INFORMATION
WAS MISSED BY ME.
SO THIS HELPS REMIND US THE
ACTION STEP TO GET BETTER AT
DIAGNOSIS IS TO DISCARD THE OLD
NOTION OF A SOCIAL HISTORY AND
ASK PEOPLE ABOUT A TRUE SOCIAL
HISTORY.
ONE THAT SHOWS US THE WORLD THEY
INHABIT, THE WORLD THAT MATTERS
TO THEM AND MAY HAVE THE ANSWER
TO THEIR DIAGNOSTIC QUANDARY.
ONE CONCEPTUALIZATION, IT'S A
COGNITIVE ACTIVITY, THE BRAIN
AND COMPUTATIONAL MODES.
WE THINK ABOUT THE PROCESS,
WELL, IT'S MY BRAIN, THE
PATIENT'S BRAIN, MAYBE NOW THE
COMPUTER, AND TOGETHER THE THREE
OF US ARE GOING TO SOLVE THIS
CASE.
WHAT I'VE LEARNED FROM MANY
COLLEAGUES AND SOME EXPERIENCES,
THAT WE'RE NOT ALONE IN THE
ROOM.
THE IDEA THAT MY BRAIN AS AN
INSTRUMENT, THE PATIENT'S BRAIN
AS A PURVEYOR OF INFORMATION,
AND EXPERTISE IN THE BODY, THE
COMPUTER TO BUTTRESS THE PROCESS
IS NOT ENOUGH, NOT EVEN THE
WHOLE INFLUENCE IN THE
DIAGNOSTIC PROCESS, THAT THERE'S
A LOT OF BIAS THAT IS INJECTED
INTO THIS PROCESS AND IT'S IN
MORE WAYS THAN WE KNOW.
I THINK ONE OF THE THINGS THAT
HAS COME ABOUT IN THE LAST TWO
TO THREE YEARS WHICH HAS BEEN
UNKNOWN TO US BUT NOW WELCOME
INSIGHT, THAT MANY OF THE TOOLS
WE USE IN DIAGNOSIS ARE BIASED.
BE THEY AROUND RACE, ETHNICITY,
OR GENDER, BUT WE'RE LEARNING
LIKE THE PULSE OXIMETER, PEOPLE
WITH DARKER SKIN, SICKER THAN WE
MIGHT BE AWARE OF BUT IN SOME
WAYS WE INSIGHTS WHETHER
PULMONARY FUNCTION, PULSE OX,
EGFR, HAD HE -- THEY FEEL LIKE A
TECHNICAL FOIBLE OF THE PAST,
PERHAPS WE CAN START OVER AND DO
A BETTER JOB WITH BUT THE THING
I'M TALKING ABOUT ISN'T
DIAGNOSTIC TOOLS LIKE THIS BUT
OUR MINDS, THE MOST IMPORTANT
INSTRUMENT.
MY COLLEAGUE DENISE CONOR HERE
AND OTHER COLLEAGUES TAUGHT ME
TO OPEN MY EYES TO THE IDEA WHEN
WE'RE IN THE ROOM IT'S NOT TWO
BRAINS AND THE COMPUTER, WE'RE
OPERATING IN A SOCIAL AND
HISTORICAL CONFECTION
INFLUENCING A LOT.
WAIT PEOPLE HAVE BEEN TREATED BY
THE HEALTH SYSTEM, AND HOW MUCH
AGENCY THEY FEEL WHEN THEY ARE
TRYING TO GET HELP AND GIVE
INFORMATION, AND COLORS THE WAY
MY BRAIN PROCESSES INFORMATION,
WHETHER I LIKE TO ADMIT IT OR
NOT.
DOCTORS ARE A SOCIAL PRODUCT
INFLUENCED BY SOCIETY WE'RE IN.
NEITHER ONE OF THOSE TWO BRAINS
IS OPERATING IN A PURE COGNITIVE
MODE, HEAVILY INFLUENCED BY THE
SOCIETY IN WHICH WE LIVE, AND
EVEN THE HEALTH SYSTEM WHICH HAS
INNATE BIAS AND INEQUITIES BUT
APPRECIATE HOW MUCH IT AFFECTS
THE JUDGMENT INSTRUMENT.
THERE'S MANY WAYS THIS HAPPENS.
OFTENTIMES WHEN WE'RE TREATING
PEOPLE OR SEEKING CARE THE BRAIN
NATURALLY CATEGORIZES PEOPLE
INTO IN GROUPS AND OUT GROUPS IN
AN AUTOMATED WAY, IT'S NOT
AWARE, DOESN'T HAVE ANY INTENT
BUT WE NATURALLY CATEGORIZE
PEOPLE AS BEING MORE LIKE US OR
BEING LESS LIKE US.
THIS HAS REALLY IMPORTANT
IMPLICATIONS.
PEOPLE ARE IN OUR IN GROUP, MY
GENDER, RACE, GEOGRAPHIC,
SOCIOECONOMIC STATUS, MY
PROFESSION, WHATEVER IT IS, YOU
TEND TO BE MORE CHARITABLE TO
THEM, MORE INTERESTED, TEND TO
REMEMBER MORE, TEND TO EXTEND
PEOPLE MORE GRACE AND TEND TO GO
THE EXTRA MILE.
THE MORE PEOPLE ARE OUTSIDE OF
THE GROUP THAT OUR BRAIN
SUBCONSCIOUSLY MAKES AN
ASSIGNMENT TOO, THE LESS LIKELY
WE ARE TO GO THE EXTRA MILE,
WITH IMPLICATIONS, COGNITIVE AND
PHYSICAL.
IT'S SUBTLE, WE WOULD NEVER BE
AWARE OR ADMIT IT BUT THIS IS
WHAT HAPPENS EXPERIMENT AFTER
EXPERIMENT.
MANY PEOPLE HAVE SAID THIS IS
ONE OF MANY PROBLEMS, BUT I WANT
TO NOT TALK ABOUT SORT OF LIKE
THE SOCIETAL AND PROFESSIONAL
THINGS WE HAVE TO DO TO ADDRESS
THOSE INEQUITIES, WORTHY OF ITS
OWN TALK.
BUT JUST THINKING OF
DIAGNOSTICIAN IN THE ROOM,
WHAT'S ONE THING I COULD DO IN
THE ROOM TO TRY TO NEUTRALIZE
THIS THING MY BRAIN DOES
AUTOMATICALLY?
MY COLLEAGUE KIMBERLY MANNING,
DR. CAPERS, THE IDEA OF
INDIVIDUALIZATION.
WHICH IS THAT EVEN IF IT'S
OBJECTS TO US THAT WE'RE IN
DIFFERENT DEMOGRAPHIC GROUPS
THERE'S SOMETHING WE HAVE IN
COMMON, AND THE SKILLED
CLINICIAN, CARING PERSON, WILL
FIND THAT.
SO THAT YOU WILL FIND SOMETHING
IN THE COURSE OF THAT SOCIAL
HISTORY THAT I MENTIONED THAT
CONNECTS US.
MAYBE WE GREW UP IN THE SAME
PLACE, MAYBE WE BOTH HAVE
TEENAGE SONS, MAYBE WE BOTH HATE
HAVING TO WAIT FOR PARKING AT
THE HEALTH CENTER, WHATEVER IT
IS, FIND SOMETHING YOU HAVE IN
COMMON.
WHAT WE FIND IS THAT WHEN YOU
FIND JUST ONE COMMON GROUND WITH
THE PERSON, TRUST IS ENHANCED,
INFORMATION EXCHANGE IS
ENHANCED, AND THE COGNITIVE
EFFORT AND PHYSICAL EFFORT THAT
WE EXHIBIT FOR THE PATIENT GOES
UP.
IT'S A SMALL STEP.
WE HAVE BIGGER ISSUES TO DEAL
WITH THAN JUST INTERACTION IN
THE ROOM AT SOCIETAL AND
PROFESSIONAL LEVEL BUT FINDING
COMMON GROUND,
INDIVIDUALIZATION, IS ONE WAY TO
MITIGATE BIAS FROM THE
INFORMATION PROCESS WHEN
TREATING ACROSS DIFFERENCES.
NOW, THIS IDEA OF IMPLICIT BIAS
IN INTERACTION IS RELATIVELY
NEW, NOT IN SOCIAL SCIENCE
DISCUSSED FOR DECADES BUT IN
MEDICAL SCIENCE WITH A
RENAISSANCE IN THE LAST COUPLE
YEARS.
ONE THING IN THE MEDICAL
LITERATURE LONGER THAN IMPLICIT
BIAS IS COGNITIVE BIAS.
COGNITIVE BIAS IS POPULARIZED
BECAUSE IT'S IN POPULAR LOOKS.
SO IF YOU TAKE AN AUTHOR LIKE
MALCOLM GLADWELL, YOU WILL TALK
ABOUT THE BRAIN, DANIEL CONEMAN
WILL TALK ABOUT THE FOIBLES OF
THE BRAIN.
BOTH ARE RIGHT, ACCURATE
CHARACTERIZATION OF THE BRAIN.
A BIAS IS A PREDICTABLE
DEVIATION, BUT ONE OF THE THINGS
TO EMPHASIZE IS A BIAS IS A LOT
LIKE A MIRAGE.
JUST BECAUSE YOU SEE IT DOESN'T
MEAN YOU CAN TRICK YOUR BRAIN
INTO BELIEVING IT DOESN'T EXIST
AND DOESN'T NECESSARILY IMPLY WE
SHOULD TRY TO AVOID THEM.
LET ME DELVE AND GIVE A PRIMER
OF JUST A COUPLE BIASES.
ANCHORING BIAS, THE IDEA ONCE
THE BRAIN FORMS AN IDEA WE LOCK
IN.
LIKE, YOU KNOW, I THINK OF THIS
PATIENT HAVING A MIGRAINE
HEADACHE AND DON'T ADJUST, EVEN
IF THE NEURO EXAM HAS A SLIGHT
ABNORMALITY OR FEVER, I'LL STICK
TO MY GUNS AND CALL THIS
MIGRAINE HEADACHE EVEN THOUGH
THERE'S A CONTRADICTING
INFORMATION.
THERE'S THE AVAILABILITY
HUERISTIC, THAT THE BRAIN IS NOT
GOOD AT JUDGING THE PROBABILITY
OF THINGS ALONE, HEAVILY
INFLUENCED BY WHAT'S RECENT OR
SALIENT SO IF A PATIENCE COMES
WITH A HEADACHE, THE GOOD CHANCE
IT'S A MIGRAINE, BUT IF LAST
WEEK I MADE A MISTAKE AND MISSED
A PATIENT WITH A SUBARACHNOID
HEMORRHAGE, I'M GOING TO FOR
THIS PATIENT WILDLY OVERESTIMATE
THE POSSIBILITY OF A
SUBARACHNOID HEMORRHAGE.
OUR BRAIN IS HEAVILY INFLUENCED
BY WHAT HAS EMOTIONAL VALENCE,
NOT GOOD AT RATIONALLY
CALCULATING BASE RATE.
THERE'S THE ISSUE OF
CONFIRMATION BIAS WHICH DOESN'T
COME UP IN MEDICINE AS IN THE
NEWS, WHICH IS WE SEEK
INFORMATION THAT CONFIRMS OUR
INITIAL IMPRESSIONS.
SO IF I THINK HAVE YOU THIS
DISEASE, I MIGHT CONTINUE TO
SEND TESTS AND LABS FOR THAT
DISEASE, NOT NECESSARILY SEEKING
ALTERNATIVE INFORMATION.
A COUSIN OF THE ANCHORING BIAS.
THERE'S EXAMPLES AND STUDIES IN
MEDICINE, POPULAR IN POPULAR
PRESS, AND BECAUSE OF THAT THE
HOPE IF WE COULD IDENTIFY THEM
AND EXTINGUISH THEM WE MAY
IMPROVE DIAGNOSTIC REASONING.
BUT THAT'S PROVED HARDER THAN WE
THINK.
ONE OF THE PROBLEMS IS THAT WE
ONLY USE THIS LANGUAGE OF
HUERISTICS AND BIASES WHEN CASES
HAVE BAD OUTCOMES.
THAT MAKES US FORGET THAT
ACTUALLY MOST OF THE TIME THAT
SAME MENTAL MACHINERY WORKS
REALLY WELL.
I'LL GIVE AN EXAMPLE FROM THE
WORLD OF SPORTS.
IMAGINE THAT IT'S THE END OF THE
GAME, HIGH RISK/HIGH RETURN
MOMENT, THE COACH HAS TO MAKE A
CALL WHETHER THE TEAM GOES FOR A
PLAY.
HIGH RISK BUT HIGH RETURN IF
THEY WIN.
IF THE TEAM GOES FOR THE PLAY ON
THE COACH'S CALL, GONE THROUGH
THE DECISION-MAKING PROCESS AND
SHE MAKES THE CALL, AND THE TEAM
SCORES, AND THEY WIN THE GAME,
THE ADJECTIVES THAT WOULD BE
APPLIED WOULD BE GUTSY,
VISIONARY, BRILLIANT.
IF THAT COACH GOES TO THE EXACT
SAME DECISION-MAKING PROCESS,
WEIGHS THE FACTORS, MAKES THE
DECISION TO GO FOR THE PLAY BUT
THE TEAM DOESN'T GET IT, DON'T
GET THE SCORE, THEREFORE THEY
LOSE THE GAME, THE COACH WILL BE
CALLED SHORT-SIGHTED, FOOLISH,
INEXPERIENCED, OTHER ADJECTIVES
WILL BE PULLED OUT EVEN THOUGH
THE DECISION-MAKING PROCESS IS
THE SAME.
THAT'S BECAUSE THE HUMAN BRAIN
IS NO GOOD AT JUDGING
DECISION-MAKING PROCESS, ONLY
OUTCOMES, SHOWN IN STUDIES OF
DOCTORS AND LAWYERS.
WHEN YOU GIVE DOCTORS A BAD
OUTCOME THEY ASSIGN A LOT OF
HUERISTIC AND BIAS LABELS TO A
CASE, THREE IN ONE STUDY, IF THE
PATIENT HAS A GOOD OUTCOME WITH
THE EXACT SAME DECISION-MAKING
PROCESS TO THE VERY LAST MINUTE,
DOCTORS CAN ONLY FIND ONE
HUERISTIC AND BIAS.
SO, AS AN EXAMPLE IF I'M WORKING
IN THE EMERGENCY ROOM AND
PATIENT HAS ACUTE ONSET OF FLANK
PAIN, HEMATURIA, SOUNDS LIKE A
KIDNEY STONE.
BUT THE CAT SCAN IS NEGATIVE.
A GOOD TEST FOR KIDNEY STONE.
IF I CONTINUE TO HOLD ONTO MY
HYPOTHESIS FOR KIDNEY STONE,
SOMEONE MAY BE LIKE, THAT GUY IS
ANCHORING, TOTALLY STUCK ON THAT
DIAGNOSIS, WILL NOT BUDGE EVEN
IN THE FACE OF CONTRADICTING
INFORMATION.
AND THAT WILL BE CALLED
ANCHORING BIAS.
BUT IF THE PATIENT COMES IN THE
NEXT DAY WITH THE KIDNEY STONE
THAT THEY STRAINED OUT, HERE,
DOC, HERE IS THE STONE, THEN
I'LL BE CALLED A BRILLIANT
DIAGNOSTICIAN.
THAT'S THE WAY THE BRAIN WORKS.
CANNOT JUDGE DECISION-MAKING
PROCESSES WELL, ONLY OUTCOMES.
AND WE USE THE VOCABULARY IN
RETROSPECT.
THE IMPLICATIONS FOR DECISION
MAKING HERE HUERISTIC AND BIASES
ARE NOT A BUG IN OUR PROGRAM,
THEY WORK SO MANY TIMES, THEY
ARE AN ESSENTIAL FEATURE OF THE
PROBLEM SOLVING HARDWARE.
IF IT DIDN'T WORK, WE
WOULDN'T -- IF WE DIDN'T USE IS
WE WOULDN'T BE ABLE TO GET
THROUGH OUR DAY.
THAT MAKES THEM FALL SHORT AS
EFFORT FOR QUALITY AND SAFETY
EFFORTS, EFFORTS TO EXTINGUISH
BIASES WOULD COME AT THE COST OF
ALSO EXTINGUISHING TIMES THAT
EXACT SAME THOUGHT PROCESS,
COGNITIVE BIAS I SHOULD SAY, LED
TO THE CORRECT DIAGNOSIS, LESS
SOMETHING TO EXTINGUISH, MORE
SOMETHING TO BE AWARE OF.
EVEN DANIEL CONEMAN, WHO I
MENTIONED BEFORE, GODFATHER OF
THE FIELD OF HUERISTICS SAID AT
THE END OF "THINKING FAST AND
SLOW," AT THE END HE SAYS I'VE
STUDIED, HAVE WRITTEN, GOT THE
NOBEL PRIZE FOR IT.
EVEN STILL I MIGHT RECOGNIZE A
FEW SITUATIONS WHERE I'M AT RISK
BUT FOR THE MOST PART STILL
BETTER AT SEEING OTHER PEOPLE
THAN I AM MYSELF.
THAT'S ONE TRUISM OF BIAS.
WE CAN EASILY SEE THEM IN OTHER
PEOPLE BUT DON'T HAVE AN EARLY
ERROR DETECTION SYSTEM TO CATCH
THEM IN OURSELVES.
THE NEXT ACTION STEP IS THE HALL
OF JUSTICE, I'LL GET TO THAT IN
A SECOND.
IT STARTED WITH A STORY ABOUT A
PATIENT WAS BROUGHT BY
AMBULANCE, SOCIALLY ISOLATED, A
MAN, NOT MUCH CONTACT FOR MANY
YEARS, LIVED IN AN APARTMENT,
LANDLORD WAS WORRIED.
HE WAS CONFUSED, LOSING WEIGHT,
KIND OF INCOHERENT, A LOT OF
BRUISING.
THIS LED TO A MAJOR WORKUP
TRYING TO FIGURE OUT THE CAUSE
OF THE SYSTEMIC DISEASE, IN
CONFUSION, BREEZING, WEIGHT
LOSS, A SEARCH FOR ENDOCARDITIS
WAS FRUITLESS, SOCIAL PHENOMENON
LIKE ELDER ABUSE, BUT THAT
WASN'T VERIFIED.
INTENSE BIOMEDICAL WORKUP WITH
ENDOSCOPY, LOOKING FOR CANCER,
SCANNED, SCOPED.
ALL OF THAT CAME UP NEGATIVE.
HE CONTINUED TO HAVE BLEEDING.
ONE DAY HAD A SPONTANEOUS BLEED
IN THE HIGH CONVEYED BY CT SCAN,
AND DESPITE GENERALIST,
RHEUMATOLOGIST, HEMATOLOGIST,
LAB MEDICINE THINKING ABOUT THIS
CASE WE DIDN'T COME UP MUCH,
LIKE $100,000 IN THE HOLE BUT
NONE THE WISER ABOUT WHAT WAS
GOING ON WITH HIM.
ONE DAY A TEAM MEMBER, THE
DIETICIAN, CAME OUT OF THE ROOM
AS DOCTORS WERE ROUNDING AND
SAYS, YOU KNOW, I'VE BEEN
OBSERVING HIS TRAY, AND HE ONLY
EATS CERTAIN FOODS.
THAT'S INTERESTING, NOT REALLY
BELIEVING IT WOULD BE
INTERESTING, WONDERING WHERE
THIS WAS GOING.
SHE SAID, YOU KNOW, HE EATS HIS
MAIN MEAL BUT NEVER TOUCHES THE
VEGETABLES OR THE FRUIT.
SHE SAID, DID YOU KNOW IT
BOTHERS HIS STOMACH?
OH, YEAH, WE KNOW HE HAS A
SENSITIVE STOMACH, PUT HIM ON A
PPI TO TAKE CARE OF THAT.
CURIOUS, HE NEVER HAS FRUIT.
EVER.
HE NEVER EATS HIS VEGETABLE.
WHAT SHE WAS TRYING TO SAY IN A
GENTLE WAY WAS THAT WHAT HE DID
NOT NEED WAS ANOTHER SCAN OR
DOCTOR OR ANOTHER TEST.
MORE THAT WE PROBABLY NEEDED A
HISTORY LESSON.
WHAT HAD HE WAS A DISEASE THAT
GOES BACK TO THE AGE OF SAIL, A
TIME WHEN SHIP TECHNOLOGY
EXPANDED, SO THAT SHIPS COULD GO
ON LONG DISTANCES FOR COMMERCE
OR EXPLORATION BUT THE PRICE
PAID BY SAILORS ON LONG TRIPS
THEY COULDN'T CARRY FRESH
PRODUCE, THEY HAD TO CARRY
THINGS WITH PRESERVED LIVES,
THEY DID THEIR CONQUEST, BUT
MANY DIED ALONG THE WAY, MANY
WHO CAME BACK CAME BACK LOOKING
LIKE THIS BECAUSE THEY HAD A
COMPLETE ABSENCE OF VITAMIN C,
UNBEKNOWNST TO THEM AT THE TIME.
THEY WOULD ONLY HAVE KNOWN THIS
AS SCURVY.
TURNS OUT THIS MALADY,
CHARACTERIZED BY FRAGILITY OF
BLOOD VESSELS AND CONNECTIVE
TISSUES BECAUSE OF THE ROLE OF
COLLAGEN INTEGRITY WAS THE SAME
THING CAUSING THE BRUISING AND
WEIGHT LOSS IN OUR PATIENT,
SEVERELY MALNOURISHED, NEVER
TOUCHED FRUITS AND VEGETABLES.
DESPITE ALL THE TECHNOLOGY AND
DOLLARS AND CONSULTANTS IT WAS A
REMINDER TO MOVE AWAY FROM THE
IDEA OF DOCTOR AS
SUPERDIAGNOSTICIAN TO SOLVE THE
CASE AND MOVE INSTEAD TO MORE OF
A HALL OF JUSTICE APPROACH
LEANING ON ALL MEMBERS OF THE
TEAM, EVEN CONCEPTUALIZED AS
BEING ABLE TO SOLVE THE CASE.
MANY TIMES I HAVE MANY
RECOLLECTIONS ONCE I STARTED TO
GET BETTER, I DON'T WANT TO SAY
I'M GOOD BUT BETTER, THE
PHYSICAL THERAPIST PICKED UP
PARKINSON'S DISEASE I MISSED,
THE NURSE HAS PICKED UP WHAT
ANTIGEN IS CAUSING
HYPERSENSITIVITY, THE PHARMACIST
RECOGNIZED A DRUG CAUSING A DRUG
REACTION.
I'M HAPPY TO SAY THINGS LIKE,
OH, I LOVE IT WHEN THE
PHARMACIST CATCHES MY MISTAKE OR
LISTEN TO YOUR NURSES, THEY KNOW
WHAT'S GOING ON, THEY GET
PARROTED IN HALLWAYS AND SOCIAL
MEDIA, THEY ARE SAGE ADVICE.
WHAT I'M TALKING ABOUT IS
SOMETHING MORE ACTIVE.
THIS WAS IN PRACTICE, NOT
WELCOMING WHEN THEY SAY IT ABOUT
YOU REACHING OUT TO OTHER
MEMBERS AND ASKING WHAT DO YOU
THINK MIGHT BE GOING ON?
THAT EXTENDS TO THE PATIENT AND
FAMILY.
BUT OFTENTIMES WE FAIL TO
CAPITALIZE ON POTENTIAL
KNOWLEDGE IN DIAGNOSTIC TEAM.
ACTION STEP IS TO MOVE AWAY FROM
SUPER HERO MODEL AND GO TOWARDS
THE HALL OF JUSTICE MODE
PARTICULARLY FOR COMPLEX CASES
WE HAVE.
ONE OF THE KEY ELEMENTS OF
PROBLEM SOLVING IS TO GET THE
RIGHT ANSWER, ONE OF THE BEST
WAYS TO ASSESS FOR REASONING,
CORRECTNESS OF ANSWER.
YET MANY OF US ARE SCARED BY
OCCASIONS IN THE SCHOOL YEARS
WHEN WE TURNED IN A PROBLEM SET
MAYBE FOR MATH CLASS OR SCIENCE
CLASS WHERE WE TURNED IN THE
SET, GOT ALL THE ANSWERS RIGHT
AND THE TEACHER PUT A RED MARK
ON EVERY ONE AND GAVE US 50%.
I'LL ASK YOU TO THINK, WHY IS
THAT?
WHY IS IT THAT YOU GOT ALL THE
ANSWERS RIGHT BUT ONLY GOT 50%
CREDIT INSTEAD OF 100%?
WHAT MIGHT BE ECHOING AROUND,
YOU DIDN'T SHOW YOUR WORK.
QUITE OFTEN WE GIVE PEOPLE A
PASS FOR SHOWING THEIR WORK
BECAUSE IT'S BOTH EFFICIENT AND
INTELLECTUALLY SATISFYING TO
KNOW WE GOT THE RIGHT ANSWER
HOWEVER VERIFIED BUT THE ACTION
STEP TO BECOMING A BETTER
DIAGNOSTICIAN AND TEACHER IS
MOVE AWAY FROM THE RIGHT ANSWER
AND TOWARDS A RIGHT ARGUMENT.
THE ARGUMENT IS THE UNIT OF
REASONING.
THINK OF YOURSELF WHEN WE SAY I
THINK THIS IS WHAT'S GOING ON
WITH THE PATIENT, MOVING AWAY
FROM THE IDEA THAT THIS IS WHAT
I THINK THEY HAVE, LIKE THE WAY
A DOCTOR MIGHT SPEAK, TO
THINKING LIKE AN ATTORNEY,
MAKING CLOSING ARGUMENTS IN A
COURT OF LAW.
WE REALLY SHARE THE RANGE OF
POSSIBILITY WE THOUGHT ABOUT AND
EVIDENCE GOING FORWARD AND
AGAINST IT.
BEFORE YOU'RE GOING TO IMPLICATE
DIAGNOSIS BEING GUILTY, YOU HAVE
TO SHARE THE EVIDENCE FOR, AND
INTELLECTUAL HONESTLY EVIDENCE
AGAINST, BEING THE PROSECUTION
AND DEFENSE.
WHAT DOES THIS LOOK LIKE?
IN THE CLINICAL ENVIRONMENT YOU
CAN CREATE A STRUCTURE, I WANT
YOU TO PRESENT IN A WAY YOU CAN
LABEL THE PROBLEM, LABEL THE
SCHEMA, THE MAP OF HOW THE BRAIN
ORGANIZES THE PROBLEM BUT WHEN
WE GET DOWN TO POSSIBILITIES
SPEAK IN TERMS OF PROBABILITY,
NOT DEFINITIVENESS AND SHOW ME
ARGUMENT FOR OR AGAINST.
WHEN YOU START DOING IT, BETWEEN
BOTH TEACHER AND TEAM IT WINDS
UP BEING A REASONING
CONVERSATION AND CLEAR TO THE
TEACHER WHERE THEY DON'T NEED TO
COVER BECAUSE THE REASONING IS
SOUND AND WHERE THEY DO NEED TO
INTERVENE, WHETHER IT'S THE
PROBABILITY ASSESSMENT OR DATA
USED FOR AND AGAINST IT.
IF I WAS TO SUMMARIZE THIS, IT
MEANS TO ACT IN THIS WAY,
ACTUALLY TO RELINQUISH A PHRASE
YOU SOMETIMES SAY, JUST PUT YOUR
NICKEL DOWN.
MODE OF DEFLATION, IT'S GETTING
BETTER AT ASKING FOR A PENNY FOR
YOUR THOUGHTS, NOT PUTTING THE
NICKEL DOWN.
BUT THAT PENNY HAS TO COME WITH
REASONING AND KNOWLEDGE, THE
VIRTUE OF UNDERSTANDING GREAT
REASONING PROCESSES, FOR
DIAGNOSIS AND FOR MANAGEMENT.
CONCLUDING TIP RELATES TO BOOKS.
MUCH OF WHAT WE DO IN TERMS OF
REASONING TO GET BETTER IS
SPENDING OUR TIME IN THE MEDICAL
LITERATURE.
BOOKS, JOURNALS, SOCIAL MEDIA,
WEBSITES, WHEREVER THAT
KNOWLEDGE IS, BUT THERE'S WISDOM
TO BE GAINED OUTSIDE OF
MEDICINE, ONCE YOU RECOGNIZE
THAT THE MOST IMPORTANT
DIAGNOSTIC TOOL IS NOT THE CHEM
7, CT SCAN, IT'S YOUR OWN MIND.
I'LL RECOMMEND THREE BOOKS, ONE
IS "NOISE," THE FOLLOW-UP TO
"THINKING FAST AND SLOW,"
MARVELOUS.
POINTS OUT THAT WE COULD BE
BIAS, THE FIRST BOOK IS ABOUT BY
AS, BEING WRONG IN ONE DIRECTION
BUT THE SECOND BOOK POINTS OUT
ANOTHER PROBLEM THAT WE HAVE,
THAT WE CAN BE INCONSISTENT WITH
THE SAME JUDGMENT.
THIS CAN BE WHETHER IT'S JUDGES
GIVING PAROLE SENTENCES, WHETHER
IT'S A BANK LOAN OFFICER
DECIDING WHO DOES OR DOESN'T GET
A LOAN OR DOCTOR LOOKING AT
X-RAY AND SEEING FOR ONE PATIENT
MAKING ONE CALL AND LOOKING AT
THE SAME X-RAY AND HOUR LATER
MAKING THE OTHER CALL.
THAT THERE'S A LOT OF NOISE OR
VARIABILITY IN OUR JUDGMENT,
UNWANTED VARIATION.
NOISE TALKS ABOUT WAYS TO
RECOGNIZE IT AND MITIGATE IT.
THE SECOND IS "PEAK."
THE UNDERLYING FRAMEWORK FOR THE
WORK I'M OUTLINING HERE IS
CALLED THE EXPERTISE SCIENCE
APPROACH, IF YOU'RE TRYING TO
GET GOOD AT SOMETHING, YOU'RE
NOT TRYING TO GET EXPERIENCE,
YOU'RE TRYING TO GET EXPERT.
THERE'S AN EXTRA FORM OF HARD
WORK THAT'S REQUIRED.
ERICKSON WAS ONE OF THE PIONEERS
OF THE CONCEPT OF DELIBERATE
PRACTICE AS A WAY TO DOING THAT,
AN ACCESSIBLE WAY TO
UNDERSTANDING, HE DOESN'T HIDE
IT'S HARD WORK,TELLS YOU WHAT
THE HARD WORK IS LOOK LIKE IF
YOU'RE TRYING TO GET PHYSICAL,
PSYCHOMOTOR, COGNITIVE
EXPERTISE.
MY FAVORITE BOOK OF ALL IN THE
TRIO, I LOVE ALL THREE, "SUPER
FORECASTING."
IT'S THE STORY OF PEOPLE WHO
HAVE OUTSTANDING JUDGMENT.
HIS LARGELY CENTERS ON THE GOOD
JUDGMENT PROJECT, CROWDSOURCING
PEOPLE FROM ACROSS THE WORLD,
ACROSS THE COUNTRY MAKING
POLITICAL JUDGMENTS.
WILL NORTH KOREA DO THIS?
WILL GREEN LAND DO THAT, WILL
RUSSIA INVADE UKRAINE?
HE HAS PEOPLE MAKE PREDICTIONS
AND CHECKS THE WORK.
A SMALL SUBSET ARE SUPER
FORECASTERS, NOT GOVERNMENT
AGENTS, DON'T HAVE ACCESS TO
CLASSIFIED INFORMATION.
INSTEAD, THEY HAVE VERY UNIQUE
HABITS OF MIND.
AND THIS IS WHAT I WANT TO
CONCLUDE ON, HABITS OF MIND OF
SUPERFORECASTERS, AFTER ALL
THAT'S WHAT DIAGNOSIS IS,
DIAGNOSIS IS MAKING A FORECAST.
IT'S A PROBABLISTING JUDGMENT.
WE GET CONFIRMATORY TESTING BUT
A HUGE NUMBER IS PROVISIONAL
HYPOTHESIS.
AND THE SUPERFORECASTERS WHO
MAKE THESE JUDGMENTS BETTER THAN
EVERYONE ELSE HAD THIS MINDSET,
HYPOTHESES THAT GREENLAND WILL
DO THIS OR NATURAL GAS PIPELINE
WILL BE CUT OFF, HYPOTHESES TO
BE TESTED, NOT TREASURED,
CONSTANTLY ADJUSTING THINKING.
THEY HAVE A CONSTANT
POINT-COUNTERPOINT TO THE POINT
THEY ARE SUPERSKILLED AT
UPDATING FORECASTS BUT DO IT IN
A SLIGHTEST OF WAYS.
THEY DON'T SWING FROM ONE
OPINION TO ANOTHER.
THEY DON'T SAY THIS IS CHF, OH,
THIS TEST CAME BACK?
I'M SWITCHED TO PNEUMONIA.
THIS LOW LEVEL MAKES IT LESS
LIKELY IT'S CHF, SLIGHTLY
INCREASES PROBABILITY MIGHT BE
PNEUMONIA, SPEAKING IN A NUANCED
WAY.
MIGHT CHANGE THEIR MIND BUT MAKE
MINOR ADJUSTMENTS.
THE DRAGONFLY BEAUTIFUL AT
DISTANCE, HAS COMPLEX EYES, OVER
3,000 -- 30,000 LENSES, ALLOWS
IT TO LOOK ALL AROUND, LIKE A
360 VIEW.
EVERY ONE OF THE LENSES TAKES IN
A LITTLE BIT OF INFORMATION BUT
IT'S THE MAGIC THAT HAPPENS IN
THE BRAIN, SYNTHESIZING LOTS OF
PIECES OF INFORMATION AND
SLIGHTLY ADJUSTS ACCORDINGLY.
PEOPLE WHO HAVE THAT HABIT OF
MIND BUT MOST IMPORTANTLY TREAT
THEIR HYPOTHESES AS SOMETHING TO
BE TESTED NOT TREASURED WIND UP
MAKING THE BEST JUDGMENTS.
SO WHAT IT IS ON THE STORY OF
BECOMING A SUPERFORECAST OTHER
SUPERDIAGNOSTICIAN I OFFERED
THIS MENU OF THINGS, SOME FROM
LITERATURE, SOME FROM
EXPERIENCE, AND OFTEN
AMALGAMATION.
THE POINT IS THAT WE'RE ALL
DEVOTED TO A CAREER IN CLINICAL
MEDICINE, TO HELP PEOPLE.
IT'S SO INTELLECTUALLY
SATISFYING, SO IMPORTANT TO OUR
SOCIETY, AND SUCH A GREAT PUBLIC
GOOD THAT WE PROVIDE.
BUT IF WE REALLY ENGAGE IN THAT,
MORAL OBLIGATION SHOULD BE AS
GOOD AS WE CAN BE.
IT'S VERY EASY TO BECOME AN
EXPERIENCED DOCTOR BUT IT'S VERY
HARD TO BECOME AN EXPERT DOCTOR.
WHAT I OFFERED HERE IS A MENU OF
THINGS, NOT THINGS YOU DO EVERY
DAY, YOU MAY DO THEM IN
DIFFERENT TIMES OF THE WEEK,
DIFFERENT TIMES OF THE DAY,
DIFFERENT PHASES OF YOUR CAREER.
THIS IS A NON-HIERARCHICAL MENU.
BUT THEY ARE ALL WAYS TO IMPROVE
THE INSTRUMENT THAT MATTERS MOST
IN THE DIAGNOSTIC PROCESS, THE
RAIN THAT WE HAVE TO CALL UPON
AND CONTINUALLY CALIBRATE.
I HOPE WHEN YOU LOOK AT THIS
LIST YOU'LL RECOGNIZE WHAT YOU
SAID SOUNDS LIKE A LITTLE EXTRA
WORK AND THAT'S EXACTLY TRUE.
THERE'S NEVER BEEN A FIELD WHERE
PEOPLE DON'T ACHIEVE THEIR
MAXIMAL POTENTIAL WITHOUT EXTRA
WORK.
SO MY GOAL HERE ISN'T TO HIDE
THAT THIS IS EXTRA WORK.
IT IS EXTRA WORK.
MY GOAL IS JUST TO CONVINCE YOU
THAT FOR THE JOB THAT WE HAVE,
IT'S DEFINITELY WORTH IT.
THANK YOU SO MUCH FOR YOUR TIME
AND ATTENTION.
I HOPE YOU FOUND SOMETHING
USEFUL IN THIS TALK TODAY.
THANK YOU.
>>DR. DHALIWAL, THANK YOU FOR
THAT OUTSTANDING TALK.
AS I HOPE EXPECTATIONS WEREN'T
MADE TOO HIGH BUT WHATEVER THEY
WERE, YOU CERTAINLY EXCEEDED
THEM.
>>I HOPE -- THOSE TWO STUDENTS
WHO MENTIONED ME, I HOPE THEY
ARE SATISFIED AS WELL, I LIVED
UP TO THEIR EXPECTATIONS.
>>I SENT BOTH THE LINK TODAY
AND TOLD BOTH THEY INSPIRED
THIS.
>>MARVELOUS.
>>A NUMBER OF QUESTIONS, A
NUMBER OF THINGS ALREADY.
SO I'M GOING TO START WITH A
COMMENT.
THIS IS NOT JUST THE BEST
CLINICAL CENTER GRAND ROUNDS
I'VE EVER HEARD, IT'S THE BEST
MEDICAL EDUCATION I'VE EVER
ATTENDED.
>>THANK YOU.
>>THE SECOND IS A QUESTION.
DO YOU HAVE ANY ADVICE FOR
PRE-MEDS HOW TO JUMP START THE
PROCESS OF BECOMING A GREAT
DIAGNOSTICIAN?
>>PRE-MED IS AN INTERESTING
TIME YOU'RE NOT YET FULLY
OVERLOADED WITH MEDICAL FACTS.
SOME BOOKS I SUGGESTED, I MIGHT
MAKE THEM YOUR PRE-MED BOOKS.
WE MIGHT NORMALLY THINK I SHOULD
BEEF UP ON SCIENCE AND MEDICINE
BUT I MIGHT SAY TAKE A PAUSE AND
FOCUS ON YOUR JUDGMENT AND
REASONING PROCESS WITH SOME
OTHER BOOKS AND THEN GET THOSE
HABITS IN PLACE SO WHEN DO YOU
START CONSUMING ALL THE
BIOMEDICAL AND BIOSOCIAL
INFORMATION IN MED SCHOOL YOU'LL
HAVE A GREAT FRAMEWORK HOW TO
DEPLOY IT.
>>THE NEXT QUESTION WE HAVE,
HOW DO YOU RENEW, HOW DO YOU
STAY FRESH?
>>AH, YEAH, I LOVE MY JOB.
I THINK THAT'S PROBABLY A HUGE
PART OF IT.
I THINK IF I HAD TO GIVE ANY
CREDIT, IT WOULD BE TO TEACHING,
RIGHT?
IT'S VERY EASY TO BECOME SORT OF
COMPLACENT AND HOW MUCH I KNOW
OR SAY I'M GOOD ENOUGH OR KNOW
ENOUGH BUT IF YOU ARE IN THE
BUSINESS OF TEACHING, THE MINUTE
YOU HEAR YOURSELF TALKING,
IMMEDIATELY BECOMES APPARENT
THERE'S SOMETHING I DON'T KNOW,
THERE'S A HOLE IN MY KNOWLEDGE,
THERE'S A DEFICIT IN MY
UNDERSTANDING, AND IF YOU ARE
REALLY OBLIGATED TO MAKE IT
CLEAR FOR SOMEONE ELSE, YOU WIND
UP GOING BACK TO LEARN MORE.
SO I THINK PROBABLY IT'S
MULTI-FACTORIAL BUT TEACHING IS
AT THE HEART OF IT.
>>SO CAN I ADD SOMETHING?
MY OWN PERSONAL ADDENDUM TO THE
QUESTION, HOW DO YOU DECOMPRESS,
WHAT DO YOU DO?
>>IT'S INTERESTING, I WOULD SAY
I'M MORE -- PERSONAL, I'M MORE
LIKE A BATTERY.
I GET UP EARLY IN THE MORNING,
VERY CHARGED.
I GET TIRED BY THE END OF THE
DAY.
USUALLY A GOOD NIGHT'S REST IS
WHAT I NEED TO GET READY THE
NEXT DAY.
I'M GRATEFUL FOR A JOB THAT HAS
VARIETY, LIKE I HAVE A LOT OF
CLINICAL WORK, BUT I ALSO WORK
WITH TRAINEES, DIFFERENT SET
THINGS, AND THE V.A. IS A GREAT
HEALTH SYSTEM.
SOME SYSTEMS MAKE LIFE HARDER,
AND THE V.A. I THINK MAKES LIFE
EASIER, GREAT TO WORK IN A
SYSTEM CAN YOU PROVIDE TO YOUR
PATIENTS, THAT'S SUPER CHARGING
IN A WAY THAT IF YOU WORK IN A
SYSTEM WHERE YOU CAN'T PROVIDE
FOR YOUR PATIENTS THAT COULD SAP
ENERGY.
>>WHY DO YOU THINK THERE'S BEEN
THIS EPIDEMIC OF BURNOUT?
WHY DO YOU THINK PEOPLE LOST
SIGHT OF THE MEANING IN
MEDICINE?
>>YEAH, WORTHY OF ITS OWN TALK.
THE CONCEPT I'VE LEARNED, WHICH
TO ME IS MAYBE A BETTER
EXPLANATION, CONCEPT OF MORAL
INJURY.
I WANT TO EXPAND.
MEDICINE HAS ALWAYS BEEN A
DEMANDING PROFESSION, MANY
PEOPLE WHO GO IN ARE WILLING TO
GIVE WHAT IS REQUIRED BUT WHAT'S
BECOME MORE APPARENT IS MORAL
INJURY, A VETERAN CONCEPT, WHEN
PEOPLE GO TO A THEATER OF WAR
AND THEY HAVE TO DO THINGS THAT
VIOLATE THEIR MORALS, BECAUSE OF
THE RULES, BECAUSE OF THE
COMMANDERS, BECAUSE OF THE WAY
THE WORLD WORKS.
WHEN YOU LOOK AT MEDICINE, IT
ALSO HAS A LOT OF MORAL INJURY
TO IT.
AND YOU CAN IDENTIFY MORAL
INJURY EVERY TIME YOU SAY TO A
PATIENT, I'M SORRY.
LIKE I'M REALLY SORRY YOUR
INSURANCE ISN'T COVERING THIS,
WE DON'T HAVE AN APPOINTMENT FOR
SIX MONTHS, I'M REALLY SORRY WE
DON'T HAVE HOUSING FOR YOU.
EVERY ONE OF THOSE APOLOGIES
MAPS ONTO LIKE A SHORTCOMING IN
THE SYSTEM THAT, YOU KNOW, WE'RE
WORKING IN, VIOLATES YOUR
INTENT, WHAT YOU THOUGHT TO BE A
DOCTOR.
BURNOUT IS A SEPARATE CONCEPT,
NOT SEPARATE, SORRY, ADJACENT
CONCEPT, BUT UNDERSTANDING THAT
IF YOU DO HAVE THE ENGAGEMENT,
YOU CAN STILL HAVE THIS MORAL
INJURY, I WISH THE SYSTEM WASN'T
SO DIFFICULT TO HELP THE
PATIENTS WHICH IS DIFFERENT THAN
IT'S DIFFICULT FOR ME TO DO MY
WORK IN.
BUT THEY ARE CLOSE, FOR SURE.
>>WE'RE EXACTLY AT THE HOUR.
I CAN -- ACTUALLY MAYBE I'LL
TEXT YOU OR E-MAIL SOME OF THE
OTHER QUESTIONS.
>>I'D BE HAPPY TO ANSWER THEM.
I'D BE HAPPY TO ADDRESS THEM.
>>THANK YOU SO MUCH.
THE HONOR HAS BEEN OURS.
THERE WILL BE A LOT OF TALK AND
I'M GRATEFUL YOU CAME TO SPEAK.
THANK YOU SO MUCH.
>>IT'S MY HONOR.
I WISH I COULD BE THERE TO HEAR
THE CHATTER.
THANK YOU, AND ANYONE IS WELCOME
TO REACH OUT TO ME.
EVERYONE, HAVE A WONDERFUL DAY.