Excellent clinicians are also thoughtful mentors. Mentors are like beacons as we navigate our path forward.
Mentors are like beacons as we navigate our path in medical training and beyond. A mentor to multiple generations of trainees and one of the strongest proponents of clinical reasoning and excellence, Dr. Gurpreet Dhaliwal (Professor of Medicine at University of California San Francisco and clinician-educator at the San Francisco VA Medical Center) sat down to speak with me after delivering grand rounds at Johns Hopkins.
I asked what clinical excellence meant to him, and he put it simply:
There are two pillars of clinical excellence – one is our intellect and the other is our humanism. These are the inviolable parts. Clinical excellence now also encompasses improving the system – the one we educate in and the one we deliver care in. It is a multifaceted construct.
P-values, randomized control trials, and latest therapeutics are often the center of attention in modern medicine. But it is our thought processes and decisions that will determine how a patient gets treated. Dr. Dhaliwal explained the evolution of interest in how doctors think: “The original research started with cognitive psychologists, but after that ground work was completed, physicians have been using these concepts to be more introspective (we all want to understand how our minds operate) and to become better teachers and clinicians.”
Microlearning (making a deliberate effort to learn something new from everyday work), seeking extra challenges (e.g., app-based simulated patient encounters), and tracking how our patients ultimately fare are methods that Dr. Dhaliwal advocates in our quest to better ourselves. But how do we truly know that we are getting better as clinicians? “The lack of validated methods to judge our performance has been a hindrance in medical education,” Dr. Dhaliwal said. “As a generalist, I can be judged on innumerable metrics – diagnostic errors around chest pain, rates of appropriate antibiotic prescribing, etc. – but I’m not sure any one of those captures my progress. Having a constant quality improvement mindset – like a Plan-Do-Study-Act (PDSA) cycle – in multiple domains of our practice is probably the way forward.”
A 2006 study to assess physician perceptions of competence demonstrated that many physicians believe communication skills are innate rather than learned. However, modern conceptions and studies show that any important physician skill can be mastered over time. This growth mindset (as opposed to the fixed mindset) was popularized by Carol Dweck, PhD, in her aptly named book Mindset. Dr. Dhaliwal explains how this is pertinent to medicine:
There is a common misconception, carried forward from an old mindset in medical education, that you are born with professionalism, communication skills, or empathy. The fixed mindset of being gifted is the easy narrative. Communication is definitely harder to master and more complex than learning to tie a surgical knot or antibiotic regimen. But educators now recognize that professionalism evolves over time, empathy can be fostered, and communication is a skill that can be improved with practice.
Dr. Dhaliwal cites the book Communication Rx by Calvin Chou & Laura Cooley, which convincingly equates communication with a procedure: it has a number of steps, it improves health outcomes, and we do it nearly two hundred thousand times in our professional lives. He states “It is important to let trainees understand that they can grow and will grow in any skill. The subtlety of adding yet, for example, you are not ready to lead the family meeting yet, or you are not ready to do that central line yet, signals to them to there is room for growth and the skill is achievable.”
As recently graduated physicians start their residencies and commence their journey to expertise and excellence, Dr. Dhaliwal finished with sage advice:
While we tend to lean on the pillar of intellect in the temple of academia, remember this point (as told to me many years ago in training) – everyone here is smart, distinguish yourself by being kind.