KeyLIME Podcast #207: Expert is as expert did …

How do master clinicians reach their elite status? Read on, and check out the podcast here (or on iTunes!)

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KeyLIME Session 207:

Listen to the podcast.

Reference:

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Murthy VK, O’Brien B, Dhaliwal G. An Inquiry Into the Early Careers of Master Clinicians J Grad Med Educ. 2018 Oct;10(5):500-506.

Reviewer: Linda Snell (@LindaSMedEd)

Background

What’s a master clinician (MC)? Or who are the clinical role models who trainees aspire to be like? They are skilled diagnosticians, compassionate communicators, and revered teachers. They win the best teacher awards, and also the best clinician awards, their patients love them, their colleagues admire them …

How they get there – reach their elite status – is unclear.

Prior studies look at experience (e.g. time in practice) vs expertise, look at performance at a proficient not a mastery level, or look at how expert clinicians maintain excellence (not what they did early in their careers).

The activities that these expert clinical faculty pursued early in their careers are not known.

This is not just of clinical interest:  if educators know how MCs acquired mastery, this could be used to provide experiences for trainees.

Trainees who aspire to become outstanding clinicians ‘have a destination but no map to guide their early career activities.’

Purpose

Seeks to understand how top professionals, peer-defined expert clinicians, acquire, maintain, and advance their knowledge and skills, by analyzing their early career clinical experiences and learning strategies.

Outcome may provide guidance for residents, fellows, and junior clinicians interested in pursuing clinical excellence.

Key Points on Method

A retrospective, qualitative interview study of 17/28 members of the University of California, San Francisco, Department of Medicine Council of Master Clinicians*, using a semi structured interview guide regarding their early career clinical experiences and learning habits.

A semi structured interview guide:  questions about participants’ training and first clinical role (describe formative early career experiences), questions based on themes of expert diagnostic practice identified by Mylopoulos,  open-ended question to identify other formative early career behaviors and experiences.

Interviews were audio recorded and transcribed; a general inductive approach to code transcripts and to identify consistent themes.

*At UCSF the criteria to be a MC are to be peer nominated, and demonstrate excellence in 6 domains: (1) depth of knowledge; (2) talent for acquiring and sharing knowledge; (3) interpersonal and communication skills; (4) professionalism; (5) ability to provide compassionate and effective care; and (6) ability to provide high-value care. Must have 8 years in practice.

Key Outcomes

61% (17/28) master clinicians interviewed – 12 male, 5 female. ~27 years in practice; 6 GIM, rest subspecialists.

4 overlapping themes: Within each theme, participants elaborated on specific behaviors and experiences.

  1. consistent learning efforts:  early career devotion to reading, teaching, and learning by tracking patient outcomes
  2. rigorous skill development: refined specific clinical skills they considered essential to medical practice – communication, physical exam, clinical reasoning
  3. cultivating habits of mind: humanism, humility, finding joy in work, rigor in case analysis
  4. clinically rich environments: high volume, unfamiliar patients, learning from peers, having role models

Key Conclusions

The authors conclude that career learning practices of master clinicians are sorted into 4 themes that may provide guidance for residents, fellows, and junior clinicians interested in the pursuit of clinical excellence. 

They have extrapolated the MC Subthemes into Action Steps:

  • Reading – Establish a routine of reading about patient cases for 15 min daily
  • Teaching – Seek out teaching roles
  • Tracking outcomes – Establish a patient tracking system
  • Listening and communication -Enroll in training courses on communication skills and reflect on communication feedback from patients
  • Physical examination skills – Practice and obtain feedback on specific examination skills
  • Clinical reasoning skills – Rehearse clinical reasoning by reading case reports (pause at fixed intervals to reason through clinical data and compare conclusions to those of the care team or clinical discussant)
  • Humanism – Develop the habit of asking patients about their illness experiences
  • Finding joy in work – Reflect on 1 rewarding aspect of clinical work each day
  • Humility – Adopt a growth mindset by seeking the margin of knowledge or skills and by acknowledging that there is always more to learn
  • Rigorous case analysis – Deepen knowledge by routinely asking ‘‘why’’ rather than ‘‘what’’ when clinical decisions are formulated
  • High clinical volume – Seek clinical roles that maximize patient encounters
  • Practicing outside their comfort zone – Seek clinical roles that fall outside assigned duties or that involve unfamiliar patients or clinical environments
  • Learning from peers -Establish a network of colleagues to discuss clinical cases
  • Role models – Establish relationships with clinically excellent colleagues and senior faculty to emulate their clinical/teaching skills and discuss diagnostic/management challenges

Spare Keys – other take home points for clinician educators

  1. ‘Journey to expertise is complex’.
  2. Limitations: Single specialty, single site study; recall bias.
  3. The first author (and interviewer) was a resident during the study.

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