Cognitive strategies take good physicians to greatness

On-the-job learning, feedback, simulation, and deliberate practice can take a good clinician to the next level.

Gurpreet Dhaliwal, MD, thinks you can become a better doctor.

In medical school and residency, you probably thought a lot about this goal, too. “When we first take something on, we have a very steep and rapid learning curve,” said Dr. Dhaliwal, associate professor of medicine at the University of California, San Francisco.

Experts find challenges even in routine matters They dont focus on what they know They have this relentless focus on what they dont know said Gurpreet Dhaliwal MD Photo by Wavebreak Media
Experts find challenges even in routine matters. “They don't focus on what they know. They have this relentless focus on what they don't know,” said Gurpreet Dhaliwal, MD. Photo by Wavebreak Media

But then you got good at your job. “After about 4 or 5 years on the job—this happens in medicine and other professions as well—you start to become comfortable with about 80% to 90% of what walks through the door,” Dr. Dhaliwal said. The downside of that comfort is that you learn less. “Human nature is to learn tasks or skills until we are good enough and then we divert our mental energy elsewhere,” he said.

Not everyone follows that path, however, and Dr. Dhaliwal sees this as the key difference between average performance and greatness. “When you study people who are experts and say ‘What is it they do?’ they take that liberated mental bandwidth and reinvest it back into that same job,” he said.

Most of the research on increasing expertise in judgment and reasoning comes from fields other than medicine, but the lessons learned are transferrable to medical practice, according to Dr. Dhaliwal. During a session titled “Clinical Judgment: Good to Great,” held at Hospital Medicine 2014 in Las Vegas in March, he explained how.

On-the-job learning

Dr. Dhaliwal's first strategy is adapted from research on the teaching profession. Excellent teachers have been found to keep an ongoing improvement “to-do” list: “I know how to create a lesson plan, but now I need to create a lesson plan a substitute teacher can pick up. I know how to discipline a child, now I need to figure out how to discipline a child with special needs,” described Dr. Dhaliwal.

“All the teachers figure out how to do that skill when they have to,” he said. “The difference between the experienced and the expert teachers was that the expert teachers did that challenge and that learning way in advance of it actually showing up on the job.”

Expert physicians do the same. Consider a patient admitted with cellulitis, which an experienced physician could successfully diagnose and treat without difficulty. The expert approach entails finding something to learn even from this routine case.

“They'll do something like say, ‘Let me look up quickly on my phone 2 other mimics for cellulitis besides stasis dermatitis and deep venous thrombosis.’ Or they might say, ‘I'm going to be at the staff meeting at noon, I'm just going to ask the infectious disease physician if they agree with me not covering MRSA.’ Or ‘If I had my student with me, how would I work in 3 teaching points?’” said Dr. Dhaliwal. “They don't focus on what they know. They have this relentless focus on what they don't know.”

This cognitive strategy allows busy clinicians to expand their knowledge while still getting their work done. “It's worth considering what you can learn in this way, creating challenges where none currently exist. Everyone is busy, but some people figure out a way to do this in small digestible bites, without waiting for the fantasy day of reading an article or going to the library,” Dr. Dhaliwal said.


Another common way expert professionals learn from their jobs is through feedback. However, depending upon their practice setting, some physicians may not get long-term feedback on their clinical decisions, especially hospitalists. “How patients do a week later, a month later, or longer never comes,” said Dr. Dhaliwal.

“There are two pernicious effects of the lack of feedback. We leave a ton of learning on the table. Those cases are lost, never to be learned from again. The second is that it actually breeds overconfidence,” he said. “For the huge number of patients we never hear about again, the brain operates under a simple rule: No news is good news.”

His solution has been to track some patients after they leave his care. “You can't do all of them. I tried it,” he said. But when a specific case is likely to present useful feedback—for example, a follow-up CT scan scheduled in a couple of weeks—find a way to remind yourself of it.

“The residents I work with have had everything from small black books to Excel spreadsheets to tagging of the EMR—ways that they track patients and remind themselves,” said Dr. Dhaliwal.

Following up on these notes to check patients' outcomes has provided surprising feedback on his practice. “So often you find out it's something very different than you thought. I think this is the world's finest form of CME,” he said.


Another common learning strategy in other professions, including more procedure-oriented medical specialties, is simulation. But you can't climb into a simulator of medical practice. “Our most important procedure is cognition, and we haven't really taken to simulating that yet,” said Dr. Dhaliwal.

Case studies can provide a sort of simulator experience, but only if approached in the right way, Dr. Dhaliwal advised. “We can't just read cases casually,” he said. Physicians should approach case studies as if they were actually trying to diagnose and treat the patient.

That means, for starters, not reading the title of many cases. “No one walks into your clinic or emergency room saying, ‘Hi, I'm a 47-year-old man with epistaxis and granulomas.’ You've got to figure that out yourself. You have to hide that,” said Dr. Dhaliwal.

Also avoid clues provided by the specialty of the physician reporting the case. “I get surprisingly good at diagnosing adrenal insufficiency when I find out an endocrinologist is presenting abdominal pain, even though in real life I've missed that diagnosis many times,” Dr. Dhaliwal said.

Then focus on what diagnostic and treatment choices you would make at each step of the case if the patient were under your care. When you use this method, even case studies of very rare conditions can provide multiple lessons, according to Dr. Dhaliwal.

“There's a lot to learn in cases if you approach them that way, even if the end diagnosis is of minimal relevance, as it often is. ... You're going to learn clinical reasoning, dissecting all those small decisions,” he said. “It changes from being a spectator sport to a simulation exercise.”

Deliberate practice

Speaking of sports, the next concept, deliberate practice, is familiar to anyone who has ever played a sport or a musical instrument. “You've heard this all your life,” said Dr. Dhaliwal. “The music teacher says, ‘You will play this passage over 10 times until you get it perfect and then you can put it back in the whole piece.’”

To bring the same concept to doctoring, Dr. Dhaliwal described how his mentor improved his cardiac auscultation skills during a 1-month rotation in medical school.

“He went to the preop board every single night and he found every patient who was scheduled for valve surgery the next day, went to their rooms, talked to them, listened to their hearts, and then found out what their pathology was postop. He did that just for a month, but he made an enormous, quantum leap in his ausculatory skills,” said Dr. Dhaliwal. “Going around with a professor trying to listen to a few hearts here and there is practice. Finding every valvular patient in the hospital for a month and listening to them is deliberate practice.”

The typical physician probably doesn't have time for this specific exercise, but the concept of focusing intently on a skill you want to learn for a set period of time is still valid, according to Dr. Dhaliwal. “These days if you want to do deliberate practice, and it's a solitary exercise, you're probably going to have to use technology,” he said. For example, to improve your dermatological knowledge, have a different image of a rash e-mailed to you every day for 6 weeks, until you've got the common diagnoses down. “Instead of hoping to get better, focus,” said Dr. Dhaliwal.

Focusing on becoming a better physician does take significant effort, even with these learning tricks, Dr. Dhaliwal acknowledged. “Everything that I've talked about here is hard work and takes extra time,” he said.

But he is convinced that the work pays off for those willing to take it on.