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The Q-Wave: Stop and Think

By October 23, 2019 No Comments
The Q-Wave Newsletter

Welcome to October’s Q-Wave. One of the best parts of the Q-Wave is that it allows me to really expand upon some of my recent thoughts, whether they’re from presenting at conferences or within my educational videos.

I just got done teaching an advanced emergency medicine course at Yellowstone National Park, and the content was so robust. It was so useful that we’re going to re-shoot this content in Sarasota, Florida for an at home CME program.

It was very interesting because in this course we had a bunch of really experienced clinicians and some pretty new clinicians. This advanced emergency medicine course was designed for those people who work autonomously and take care of very sick people.

There are two major points that I want to cover in this month’s Q-Wave. The first is how to flip the switch, and the second is how to deeply learn, or how we master content.

Flip the Switch

What do I mean by that? Daniel Kahneman, in his book Thinking, Fast and Slow, talked about two systems of thinking. We have a system one level of thinking and a system two level of thinking.

This should make sense because you can apply this in your life. System one is where your body wants to stay. It’s passive, it has routines; you just go through the motions. You get up in the morning, and you have a routine. You don’t have to think about it. When you drive to work, you get in your car and, for the most part, you go on automatic pilot. That’s passive thinking. It’s lazy thinking. It’s not active. Quite frankly, it conserves energy, so it’s where your body and mind want to stay.

System two thinking is very different. Think about driving to work – passive, passive. You’re listening to music or an audiobook, and suddenly, a kid runs in front of you. Or someone cuts you off in traffic. You slam on your brakes, and immediately you have agitation. That agitation comes from the fact that you had to snap from system one thinking, the lazy and passive way of thinking, into a very active form of thinking. That shift can take up a tremendous amount of your energy, and it pisses you off. Getting snapped into system two thinking really bothers us on a genetic level because it uses so much energy.

Ladies and gentlemen, that’s what happens in emergency medicine, or taking care of someone sick, or really deep analytical thinking. We fall into routines. We have routines in our thinking. If you work in medicine, you may get a pattern of going to see someone with a sore throat. You have a ritualistic pattern that includes the techniques you use to make you efficient at work.

The problem is, too often, we stay in system one thinking when we should snap into system two thinking. You see someone and everything looks like bronchitis – triage nurse looks like bronchitis, vital signs look like bronchitis – but when they take a deep breath they have pleuritic chest pain. Bronchitis should not have pleuritic chest pain, not to the level you’re seeing in the patient in front of you, because you’ve seen them scores of times.

You might fight flipping the switch, thinking, “Hmm. Why the hell does it hurt so much when you take a deep breath?” You won’t work them up for pulmonary embolism. You might need 20 things in a pattern to say bronchitis. If 19 out of 20 are exactly right but one isn’t right, that one thing (in this case, the pleuritic chest pain) needs to be the thing that flips the switch into system two thinking.

You need to look at the situation with a much deeper and more critical mindset. If you do, then you’ll do a good leg exam looking for Homan’s sign. You’ll pursue them to look for pulmonary embolism.

The Best Way to Learn

We talk about learning medicine and we talk about how to learn medicine. Too often people become familiar with topics rather than master them. When it comes to learning, there are two major systems. You have a social system and a natural system. Now, a social system of learning is kind of what we do when we’re in physician assistant school or nurse practitioner school or med school.

To a huge degree, it’s a manipulative system. You cram for a test and get a good grade. Therefore, you must be smart. But we know that that doesn’t clinically apply, because medicine is a natural system. It’s like farming or fitness; you can’t manipulate it. You just have to master it. You have to know your stuff.

If you work in emergency medicine, you master some primary tools. You should have a very strong mastery of EKG interpretation, chest pain, shortness of breath and how to work up someone who’s infected. To master a disease, you need to answer the four questions of mastery.

The questions of mastery are a big part of how I help PAs study for their boards. These are the four questions:

  1. What’s the pathophysiology? For every disease, think about what’s wrong with the patient. Being able to explain it in small words, so patients can understand it, is pretty helpful for your own cognition.
  2. How do they present? Think for a second to your presentations. How do they come in? Oftentimes with chest pain – a first-year presentation. Second-year is shortness of breath. Third-year is something weird like CHF or syncope or GERD.
  3. How do we diagnose it? I’d like you to think in terms of three buckets: labs, physical exam and images (including EKGs).
  4. How do we treat it?

If you’re a physician assistant studying for your recertification exam, download our free Questions of Mastery study guide!

I want to challenge you on your thinking. One of the things I find in life and in business, is that we spend too much time in our life and our business. We don’t spend enough time working on our life and our business. Planning, strategizing. Too often we go through the day thinking, instead of stopping to think about our thinking.

That’s what I hope this episode of the Q-Wave did.

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