As an aspiring physician, medical expertise is something I hope to progressively develop during medical school, internship and residency, fellowship training, and eventually, clinical practice. The knowledge base upon which this expertise will be built has already begun to be established, though the process has often seemed disjointed and the information, to varying degrees, sometimes irrelevant. Nonetheless, a pattern of synthesis and integration has emerged that, I suspect, will be repeated and elaborated upon throughout the educational process.
I have observed medical expertise firsthand during several separate activities. First, during the summer of 2010, I was fortunate enough to work with a neuropathologist at a major biomedical research center who maintained both a clinical practice and basic science lab. I accompanied him on surgical consults and autopsies regularly throughout the summer and was repeatedly astonished at the speed and fluidity with which he operated in his field of expertise. With pathology slides, he could identify with a glance what I couldn’t decipher in an hour. During brain autopsies, he would point out dozens of gross anatomical structures that, to my untrained eyes, appeared to be non-descript, homogenous, and indistinguishable. Since then, as my knowledge has grown, I’ve come to realize that it wasn’t my eyes that failed; it was my mental model – I had no appreciation for the anatomy and so couldn’t discern its subtlies; I didn’t know the patterns, and so couldn’t recognize them.
In another setting last summer, I spent approximately four hundred hours observing physicians in several specialties, including otolaryngology, cardiothoracic surgery, pediatric surgery, and emergency medicine. In each one, though the specific expertise was different, the same quickness – in diagnosis and procedure – was readily apparent. But this time I had the additional benefit of observing expertise as it developed among medical students, interns, residents, and fellows. And as one might expect, the quickness – the automaticity – was progressive along the training timeline. Medical students were hesitant, unsure, linear, systematic, and intentional. As they progressed to interns, and interns to residents, and residents to fellows, these traits gave way to quick, confident, parallel, intuitive, and automatic judgments.
Certainly, procedural skill and efficiency was greatly improved by deliberate practice, but it wasn’t clear that this progression always resulted in improved clinical judgment. Though seniority on the training ladder more or less correlated with greater efficiency and time management, it seemed also to be associated with gist-based judgments made before all relevant information had been considered. Not only has gist-based processing been experimentally identified as the dominant paradigm among medical experts, but Adam and Reyna (2005) have provided evidence suggesting that in certain circumstances, this approach actually impairs clinical judgment.
Whatever medical specialty I ultimately practice, my expertise will have been slowly, painstakingly cultivated over a long period. At that pace, I anticipate there being plenty of time along the way to reflect on the cognitive processes underlying its growth and development.
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