Why mastery of medicine is a dangerous myth

Karen Price

14/01/2019 2:51:29 PM

Dr Karen Price discusses how to conquer impostor syndrome and ease the passage from medical school to clinical practice.

The idea of the superhero – the doctor who believes they should always go it alone and find the answer – can be a popular one in healthcare.
The idea of the superhero – the doctor who believes they should always go it alone and find the answer – can be a popular one in healthcare.

I recently saw a tweet that caught my eye. It was by a young intern in Canada, Justin Koh, who talked about putting on a brave face even though he was feeling isolated and down due to missing a stroke diagnosis.
I felt a surge of compassion, because all doctors have been in that place of putting on a brave face, of feeling like an impostor.
Thousands of interns around Australia are starting their journey as doctors this month. My daughter is among them. The uncertainties and worries I hear from her and her peers mirror my own experience. The transition from medical school to medicine is a huge step. 
So I wrote to Justin:    

As medical students, we are trained to pass exams and do so really well, but exams have right and wrong answers.
We then go into the world of complexity that is patient care, with the uncertainty of patient presentations and our own responses to uncertainty. We go from right and wrong to a world that isn’t black and white. How do we manage this uncertainty, understanding our knowledge will always be changing?
As doctors, we know that what we are taught as medical students and in our Fellowship will change.
The truth in science is a moveable feast. It’s always evolving, and especially so in the generalist phase as a young intern, resident or GP. But even for the best cardiologist, the evidence will keep changing. How we practised 10 years ago will be different to now.
Marvel has built billion-dollar empires on the idea of the superhero. That idea is widespread in medicine – the solitary superhero, mastering medicine. I would argue that medicine is instead a team sport, not a tribe of individual soldiers.

People hark back to the country doctor, who was always on call. But it’s not true now, and I don’t think it was true back then. The idea is pernicious – and unhelpful.
When we move from the world of exams to the world of people, it can be bewildering. In exams, you might have a patient presenting with 10 signs, giving you lots of certainty in diagnosis. But real patients may only have two.
This is particularly evident in general practice, where many early presentations of disease are undifferentiated. Or you might have a patient with competing health priorities. If their biggest issue is mental health, they won’t give a toss about their diabetes care.

Medicine is a team sport, not a tribe of superheroes, according to Dr Karen Price.

So what can we do? Part of it is about framing – how we conceptualise what it is we do. If we change our image of medicine to that of a team sport, it helps us feel at home with uncertainty. If we get to the limits of our knowledge, we go looking for a colleague who might know.
In this era where we are finally focusing on physician wellness and burnout, we have got to figure this out. We constantly work to keep our knowledge up to date and benchmark against peers and new evidence as it comes to light. But the level of knowledge is so enormous, it’s all but impossible to be on top of everything all of the time.
We must develop strategies for when we are out of our comfort zone and how to develop a safety net.
One of the challenges, of course, is for interns to feel comfortable admitting they don’t know something. Some feel that to ask a question is an admission of failure. Many work environments will support that, but some may not. You might have a senior doctor asking why you didn’t know something.
There is the med school curriculum, but there is also the hidden curriculum that holds the unwritten rules and norms and shorthand. I remember it was quite difficult at first, to master the language the specialists were spitting out. But by the end of my rotations, I’d gotten the gist. Mastering that informal knowledge takes at least 12 weeks – and then you move.
When I train medical students, I like to give them situations where they have to make decisions. It can happen that young doctors freeze, or refer everything upwards. Getting comfortable with making decisions and following through is vital, so I like to give them the opportunity to practice that leadership role.
What I’ve learned, though, is that you feel more comfortable as you go through your career. We like to get it right all the time. We want to be the good doctor because, internally, we feel there are good doctors and bad doctors – and no-one in between.
But it’s like parenting. You’re likely to be a good enough doctor if you’re learning to safety net, to ask peers, to clarify until you feel safe with your decision, and that the patient is safe with your decision. It’s a skill that has to be learned. And yes, the stakes are high, so perfectionism is not a bad thing – right up to the point where we feel we can never be human and admit we don’t know something.
My daughter has asked me similar questions. What if I ask too many questions? What if they think I’m a nuisance? I told her that her first duty is to the patient, so ask as many questions as you need to until you feel comfortable making that decision.
The only way to shake off the anxieties and stresses of impostor syndrome is time, practice and asking questions. And by talking about the issue.
No one ever masters medicine. That’s why it must be a team sport.

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Christopher D Hogan   15/01/2019 3:56:19 PM

I hesitate to disagree with a much respected colleague but there IS such a thing as mastery. However the devil is in the detail of the definition.
As I was taught it, mastery of a complex discipline such as Medicine occurs when you are confident when faced with a difficult situation. You are confident that if you do NOT know then there are very few of your colleagues who Do know!
In education theory there is much exploration of the concept of Mastery- it takes about 100,000 hours or ten years.
We do our junior colleagues a major disservice if we expect them to have mastery less than 10 years after graduation. I distinctly remember advice given to me on graduation. "We have taught you what we know but it is an approximation of our experience & learning. You are about to meet the best teachers of all- your patients"
There was one major difference in education though. I was taught to "do your best" whereas I fear that too many are taught "do not make a mistake"
Concentrating on avoiding mistakes rather than doing our best is bad. It is defensive medicine- not good medicine.

• We decrease our range of activities
• We decrease our skills
• We do only what we are certain about
• We attempt only what we expect to succeed at
• We do not attempt to improve or to experiment to improve our skills.
• We over investigate, overtreat, overmanage & engender uncertainty rather than confidence.
• We are effectively paralysed by fear, concentrating more on self-preservation than on our patient’s needs. In all my wildest dreams I never thought I would see a contraction of our scope of practice. Nor did I expect that the guidelines I had helped develop to become a foundation of practice from which we could expand would become the upper limit of our activities.
We & our younger colleagues must be given encouragement to learn & expand our skills, knowledge & research. While we like them to "be safe", this must not be interpreted as "do nothing, refer everything"
I suspect that this is the start of a very interesting conversation

Tim Leeuwenburg   17/01/2019 9:04:52 AM

Sadly the 10,000 hours idea has been debunked

Simply, there are some folk who have 10 years experience but are not 'masters' - it's just that they have repeated one year of experience ten times!

Perhaps the path is better through deliberate practice, metacognition, embracing the FOAMed paradigm and of course heutagogy