Keys to Developing Expertise

1. In the name of God Keys to Developing Expertise Intuition and Metacognition in Medical Education M. Hassani

2. Are u Lifelong Learner? The hardest conviction to get into the mind of a beginner is that the education upon which he is engaged is not a college course, not a medical course, but a life course, for which the work of a few years under teachers is but a preparation. Sir William Osler (1897, p. 161)

3. 15 minutes with a patient … • An old man • Back pain • Ringing in his ears • A bad taste in his mouth • Trouble sleeping • Headaches • Chest discomfort • Three missed appointments

4. Compare these two … The Cognitive Learner The Metacognitive Learner

5. Compare these two … The Cognitive Learner The Metacognitive Learner • Back pain • A bad taste in his mouth • Chest discomfort • Not enough time to get to all of Patient's complaints • Recommended plan for further testing in chest discomfort • Realizes that she cannot cover the entire list • Limit and prioritize • Patient`s perspective • Establish a relationship • Psychosocial issues • Missed clinic appointments: dementia and/or depression • Depression high on the differential diagnosis list • Plan: A social service referral

6. The differences between them? • Anticipating the limitation • Creating a plan and prioritizing • Coverage of the “most serious” complaints from both her and the patient’s perspective • Psychosocial insight to the problem list by including patient’s “missed appointments • Reflective and self-monitoring throughout the interview • “Contextualizes” her learning from previous experience by associating characteristics of this patient • Diagnostic knowledge and skill

7. The differences between them? Metacognitive Capabilities

8. Metacognitive capabilities

9. Metacognition • Thinking about one’s own and another’s thinking and feeling • Monitoring and management of one’s thinking: • Making plans before a thinking episode • Regulating during the episode • Reflecting back afterwards • To revise and plan future practices (Perkins & Grotzer, 1997, p. 1128).

10. Metacognitive capabilities • Self-directed learning, critical thinking, and reflective behavior (Mitchell & Liu, 1995) • Strategic knowledge • Regulatory strategies

11. Metacognitive capabilities: Strategic knowledge Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Declarative : knowledge about one’s knowledge, attitudes, feelings, and skills • Contextual: when and why to use this knowledge • Procedural: how to use and adapt this knowledge.

12. Metacognitive capabilities: Strategic knowledge Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Strategic knowledge critical to medical education: • Knowledge about one’s cognitive strengths and weaknesses related to a clinical task (one’s own learning style) • Knowledge about the patient’s knowledge and feelings regarding the presenting problem, diagnosis, or treatment plan (Others’ Perspective Taking)

13. Metacognitive capabilities: Learning Style Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Your preferred way of thinking • How we prefer to take in the environment around us

14. Metacognitive capabilities: Learning Style Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • How do I prefer to experience the learning material (visual, auditory, or kinesthetic)? • Am I more motivated to learn by exams (external) or my own interests (internal)? • Am I more abstract (theoretical) or concrete (step by step) in my approach to learning? • Do I prefer to learn from and with others or independently?

15. Metacognitive capabilities: Learning Style visual learners Kinesthetic learners • Visually oriented specialties such as dermatology and radiology • Skilled at receiving and expressing information in images, diagrams, and charts • “Hands-on” activities such as suturing and physical examination. • Actively participate in demonstrations and procedures • Specialties such as surgery and orthopedics

16. Metacognitive capabilities: Learning Style Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Improve learning-style weaknesses • Auditory learners may need to hone visual skills to effectively read and interpret radiographs or electrocardiograms.

17. Metacognitive capabilities: Perspective Taking Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • The ability to seek and share in the other’s view of the world. • Thinking about another’s thoughts and feelings • Control their interpersonal interactions and relationships through mastery of empathy, patient education, and negotiation • Develop your perspective-taking ability

18. Metacognitive capabilities: Perspective Taking Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • What is it like to be the father of a 5-year-old severely asthmatic child at midnight in the emergency room? • What is it like to be a 45-year-old mother of three children who is addicted to alcohol? • How can I convince Mrs. Jones that her child does not need an antibiotic?

19. Metacognitive capabilities: Regulatory strategies Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Monitor and control thoughts, feelings, and behaviors during a task. • Checking • Planning • Reflection • Selecting and goal setting, • Inferring • Organizing • Self-questioning • Self-assessing

20. Metacognitive capabilities: Planning Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • Needs assessment, anticipation, and prioritization • To direct objective setting • Method selection that in turn are used to control behavior and achieve goals • Performance is evaluated • The results are fed back into the process (Quirk, 1994).

21. Metacognitive capabilities: Reflection Strategic knowledge Learning Style Perspective Taking Regulatory strategies: Planning Reflection • The ability to observe and critically analyze one’s own behaviors, beliefs, understanding, emotions, and attitudes in relation to the environment.

22. TOO MUCH METACOGNITION?! • “Too much is not good.” • “Double-edged sword” • Asking too many open questions, especially when characterizing the chief complaint (overfacilitating communication) • Problem solving by generating too many hypotheses (the overextended differential diagnosis)

23. Always metacognition?! Possession and use of metacognitive abilities, however, is necessary for learning but not sufficient to developing clinical expertise. The expert physician is sometimes required to act quickly without the “luxury” of conscious thinking and planning

24. Always metacognition?! A student who relies on metacognition in an emergency can be evaluated as inefficient, a poor decision maker, or one who lacks self-confidence or clinically doesn’t get the “big picture.”

25. Thus … • Don`t become obsessive in “thinking about his thinking” and show intuitive capability. During the “heat” of clinical medicine, Don`t be paralyzed by your metacognitive capabilities

26. Intuition

27. Scenario • A teenage boy with belly pain for a few days • He looked fine and was only somewhat tender in his right lower quadrant • I do recall he had pain when I made him jump up and down. • He was overall acting fine, and my competent resident thought he was fine. • However, something inside me kept saying that I should be worried about him, so I made his mother take him to the emergency room. And of course, he had appendicitis.

28. Scenario • A 58 year old male complains of getting dizzy periodically for a week • No chest pain, shortness of breath, no recent illness. • His past history was clean • I brought him into the office immediately; he thought that ridiculous. His exam was completely normal. • I did an EKG, and it showed he had completed a heart attack. • He thinks I am a genius, I thought I was lucky. • But in retrospect, I knew. I brought him in immediately, and did the EKG, because of my experience with past patients.

29. Intuition in clinical medicine • Rapid, unconscious process • Context sensitive • Comes with practice • Involves selective attention to small details • Cannot be reduced to cause-and-effect logic (i.e., B happened because of A) • Addresses, integrates, and makes sense of multiple complex pieces of data

30. The only difference between intuition and metacognition • Intuition is not relegated to “lower-order” behaviors that rely on autonomic processes such as breathing, walking, or swimming. • Metacognition at the unconscious level • Metacognitive capabilities during medical school and residency and throughout a lifetime of clinical practice will improve both intuition and metacognition.

31. Clinical Expertise A Blend of Intuition and Metacognition

32. What is expertise? • Innate Talent / Hard Wired? • Acquired / Software?

33. Novice - expert Novice Advanced beginners Competent Proficient Expert

35. Developing From NOVICE to EXPERT • Most clinical situations encountered by the novice are new: The novice, then, must often act consciously—planning, anticipating, self-assessing, perspective taking, and reflecting in order to add meaning to experience. • Metacognition and intuition may be two complementary operating systems in the minds of clinical experts one at the conscious and the other at the unconscious level

36. Clinical Expertise

37. Keep in mind …. • Realise that clinical expertise is acquired step-by-step by intensive practice • Thinking intuitively without experience based on an analytic foundation means poor decision performance.