self-selected blind spots

“It is impossible for a man to learn what he thinks he already knows.”

Epictetus

I’m guessing Epictetus didn’t have lifelong learning in medical education in mind when he wrote this line. As a Stoic philosopher, the message was likely intended for deeper introspection. However, the lessons certainly apply to our development as clinicians.

As I reflect upon my experience as both learner and educator, I think this lesson can apply to us in many ways. Here are some warning signs that a false sense of mastery, “premature closure of expertise”, may be present. Anecdotes ahead!

For Learners

I find this particularly concerning when precepting trainees (physicians and advanced practice providers). A learner will repeatedly give affirmative statements of understanding during bedside teaching (interspersed rapid “yeah…yeah…yeah”, “sure, sure”), clearly showing they aren’t internalizing the message. We’ve probably all done this to some degree, and I suspect this is mainly a defense mechanism.

The other possibility is a loss of engagement due to relative complacency (invoke Dunning-Kruger here if you like), often in the middle to late stages of a training program.

I haven’t identified the antidote for this problem, and would love to hear some feedback in the comments. My current practice is to directly name the behavior, ask them to slow down and consider that the clinical entity and its management go deeper than they may realize.

Automaticity

At any stage of your career (internship onward), your actions and behaviors become automatic. Every case of e.g. septic shock is managed the same as the others, and importantly, hasn’t changed in a long period of time (often years, or shorter if in training). This seems like a high-risk setup to continue to practice as you were initially trained.

I don’t expect us all to pull out a textbook every time we are seeing a condition in which we are experts. This is certainly not pragmatic, nor would it be necessarily beneficial.

If we are honest with ourselves, there are probably large blind spots in our knowledge on conditions we care for on a daily basis.

  • How well do I really understand the physiology underlying this manifestation of disease?
  • What is the strength of evidence (and its effect size) for this intervention I give to patients every day?
  • Is the available evidence applicable to this particular patient? Are there aspects of this condition I could learn more deeply in order to personalize care?

Once we view our actions through this lens, it is intensely humbling to consider how vulnerable our mental frameworks may be.

Closing

Automaticity and complacency affect us all, at different times and intensities. We think about cognitive biases often in medicine, but the simplest one may be the (quasi)conscious decision not to seek out ways to deepen our learning. A healthy dose of curiosity may be a powerful antidote.

-MTS

Notes

3 comments

  1. Love your thoughts! For the eager novice, ask for a teach back, or “tell my why this isn’t x?”. For the third year fellows with one foot out the door? Harder. I try to let them run things & ask questions (like yours above – what is the evidence, what are the risks/benefits here) to which I also don’t know the answer.

    Great post!

    Liked by 1 person

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