How good of a clinician are you?

In psychology, the Lake Wobegon effect refers to a mythical town where “all the women are strong, all the men are good-looking, and all the children are above average.” In other words, humans have a tendency to overestimate their capabilities, particularly in relation to others.

As a physician, I have yet to meet a fellow doc who didn’t think that their patients loved them or that they weren’t great clinicians. And I’m no different — as a new attending, part of the reason I couldn’t wait to finish residency was my belief that I was ready to provide high-quality, cost-effective, and compassionate care — at times, maybe even better than my supervisors.

But in my first weeks as the official attending of record, I’ve found myself wondering — just how good of a clinician am I? It’s not mathematically possible for every doctor to be above average. And moreover, it’s not realistic to think that I’m excellent across every dimension of clinical practice, I’m bound to have certain strengths and weaknesses.

I’m not alone in having limited insight into my own performance. In a study, physicians were asked to solve four clinical vignettes, two designed to be easy and two difficult, and then self-rate their confidence. Despite the fact that 55 percent of clinicians got the diagnosis correct on the easy cases, and only 6 percent on the difficult ones, their self-confidence on the two sets were nearly identical.

Our “eyeball test” for evaluating ourselves and our peers in medicine is to rely on labels. We hang on to the notion that a physician with many years of practice is better than a junior attending, that internists are better diagnosticians than surgeons, that training at an “elite” academic medical center is better than training at a community hospital, or that physicians have better clinical reasoning than nurse practitioners. Yet, the data shows this is seldom the case and that exceptional and average clinicians practice and train in all sorts of settings, with widely varying backgrounds.

The problem is that there is no good way for us to assess our own skills. Licensing exams test knowledge (read: ability to memorize and regurgitate facts on cue) more than clinical reasoning.  In practice, real, meaningful feedback is hard to come by, except for the occasional patient who bounces back, files a malpractice suit, or has an autopsy.

But routine, systematic assessments on our performance are lacking and often too late to help the patient in front of us.  The ‘quality measures’ we instead focus on are related to patient satisfaction, process measures (e.g., percent of smokers counseled on quitting), or even more distant structural measures such as if we have implemented an EMR or not.

While important, none of these get to the heart of clinical medicine and what I as a clinician uniquely do, which is clinical reasoning and diagnosis.

So I recently decided to ask myself a simple question — just how good of a clinician am I? There are a number of tools I could have used: answering random questions on NEJM online; dusting off my old USMLE scores; or if I was really motivated, asking my partners to review my charts.

Instead, I used a freely available, open medical tool to measure my “clinical quotient” based on how well I reason through a case. After solving a series of brief case simulations, the tool is able to score my clinical quotient along four dimensions: Did I solve the case correctly? Did I solve it accurately? Did I solve it efficiently? And did I solve it quickly?

HDx clinical quotient - Dr. Sandeep Palakodeti - 15.09.07

The graph above illustrates my results. Overall I got 72 percent of the case simulations correct. Compared to all the other physicians and trainees who used this system, I performed at the 77th percentile on correctness, 44th percentile on accuracy, 84th percentile on efficiency, and 86th percentile on speed. As someone starting my practice at one of the top medical institutions in the world, these results didn’t do much to allay my trepidation as a newly minted attending.

But the point is that I finally have a way of evaluating myself amongst a worldwide community of other physicians all striving to hone and improve their diagnostic skills.  Evaluating my performance isn’t some version of, “Who’s the best doctor?” While that’s a fun diversion, this is really about patient care.

In my journey to provide the best possible care to the patients I serve and have a sense of belonging in the hallowed halls of medicine, being empowered with the knowledge of how I am reasoning through cases in real time is just the starting point. I hope more will join me and similarly begin their own journey into understanding themselves as physicians and healers in a more open and collegial context.

So, how good of a clinician are you?

Sandeep Palakodeti is a hospitalist.

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