2 ways to improve doctors: feedback and reflection

In medical school I used to ask myself, “When will I feel like a real doctor?” During intern year, I asked the same question. Now as a new faculty member who has completed medical school, a family medicine residency and a teaching fellowship, I still find myself asking that same question.

As primary care doctors, we are trained to churn out differential diagnoses. We must avoid premature closure or incorrectly assuming one diagnosis or management strategy without considering other less obvious possibilities. Much like House in his intellectual detective-like pursuit, we are taught to order every test, no matter how obscure, until we can solve the case.

Just as we become comfortable with one work-up and finally begin to develop a sense of confidence, we realize there is still more to learn. “Oh crap!” we think. “Why didn’t I think of that?” We compare ourselves to colleagues, question our doctoring abilities and make secret commitments to read more, learn more and try harder.

As we develop an identity as primary care doctors, we go through several phases. We begin as unconsciously incompetent — we simply are not aware of what we do not know. With more experience, we become consciously incompetent, recognizing what we do not know and desperately trying to fill those gaps. The more we see and learn, the more confident we become and soon enter the Holy Grail of being consciously competent. When a patient walks into the room with “chest pain” or “weakness,” we have a discrete algorithm in our head — our “illness script” — that allows us to quickly assess the patient and feel assured of our ability to diagnose and treat in an evidence-based, patient-centered way. We might have to look up dosing or confirm a lab test, but the general framework is in our brains and has been tested and confirmed over and over again. We feel like real doctors.

But the queasiness creeps back in when we go from consciously competent to consciously incompetent. We see a patient who does not fit one of our illness scripts or a colleague suggests a management plan that didn’t even cross our minds. We find ourselves asking that same old question, “When will I feel like a real doctor?”

Although we are groomed to become “experts” in our field, we lose sight of the reality of this goal. With countless guidelines and thousands of new papers published every day, the pressure to keep up with the latest information can seem overwhelming. Why didn’t I know that many emergency departments are now using two troponins (and not three) to rule out acute coronary syndrome in low-risk cardiac patients, that the new hemoglobin A1C goal for most diabetics is now 8 and not 7, or that peppermint oil can treat irritable bowel syndrome? Or even, why was I not an effective team leader today?

When we encounter information we don’t know, we often feel a moment of panic. We may then avoid situations in which we feel consciously incompetent unless we are taught methods to relieve the discomfort. K.A. Ericsson, a psychologist and a leading researcher on the topic of expertise, encourages people to place themselves in slightly uncomfortable situations and challenge themselves beyond their current abilities in order to practice feeling consciously incompetent.

Two things will push us to a higher level of performance: feedback and reflection. As a medical student and resident, some of my biggest “aha” moments in my professional growth came with feedback that was difficult to hear. The mere word “reflection” made me squirm. Who has time to reflect when I have 55 other responsibilities calling my name? Reflection requires us to pause from the madness, develop a new understanding, and apply that understanding to future efforts. It pushes learners along the continuum of expertise development. Otherwise, we have the tendency to continue doing the things the same way simply because we have always done them that way.

We must create environments that make feeling consciously incompetent the norm rather than the rarity. As medical students and residents, we must seek out mentors. As practicing clinicians, we must find colleagues who can listen and guide us. As teachers, we must create opportunities for our learners to reflect. We must also be willing to provide feedback that can be uncomfortable for us to give and for residents and students to hear. As learners, we must be open to feedback and take full advantage of dedicated reflection time. No matter what stage in our professional careers, we must acknowledge when we do not know something.

Primary care is an especially intellectually challenging field, as there is nothing we can tune out or ignore. With time, we learn what is most common, but we must always stay up-to-date on the latest evidence, remember to consider the less common, and continually grow our illness scripts. With each patient presenting in unique ways under different circumstances, we must keep our brains and attitudes malleable and be ready and willing to adapt. Doing so might just make us feel like real doctors.

Randi Sokol is a family physician.

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