Podcast 105 – The Path to Insanity


This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!


Full list of journals I read

The Pareto Reduction to 12

  • Ann Emerg Med – Acad Emerg Med
  • Am J Emerg Med
  • Emerg Med J
  • Br J Anaesth
  • Anesthesiology
  • Anesth & Analg
  • Resuscitation
  • J Trauma
  • Crit Care Med
  • Crit Care
  • Intens Care Med

Insight comes from Knowledge (Psychol Sci. 2006 Oct;17(10):882-90. The prepared mind: neural activity prior to problem presentation predicts subsequent solution by sudden insight.)


Mastery by Robert Greene

Pragmatic Thinking by Andy Hunt

Reading non-clinically is just as important to become an excellent physician and person, so go listen to Michelle Johnston’s lessons from the classics lecture



Critical Thinking

Rhetological Fallacies

I have a copy of this poster in both of my offices

PSYBlogs List of Cognitive Biases

If you don’t know them, you are probably committing them


Mastermind by Maria Konnokova

Thinking Fast and Slow by Kahneman


Dunning-Kruger Effect

  1. Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence [Internet]. Current Directions in 2003 Jan.;Available from: http://cdp.sagepub.com/content/12/3/83.short
  2. Caputo D, Dunning D. What you don’t know: The role played by errors of omission in imperfect self-assessments [Internet]. Journal of Experimental Social Psychology 2005 Jan.;Available from: http://www.sciencedirect.com/science/article/pii/S0022103104001210
  3. Carter T, Dunning D. Faulty Self?Assessment: Why Evaluating One’s Own Competence Is an Intrinsically Difficult Task [Internet]. Social and Personality Psychology 2008 Jan.;Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1751-9004.2007.00031.x/full
  4. Ehrlinger J, Johnson K, Banner M, Dunning D. Why the unskilled are unaware: Further explorations of (absent) self-insight among the incompetent [Internet]. Behavior and Human 2008 Jan.;Available from: http://www.sciencedirect.com/science/article/pii/S074959780700060X
  5. Difficulties in Recognizing One’s Own Incompetence: Novice Physicians Who Are Unskilled and Unaware of It [Internet]. Academic Medicine 2001 Oct.;76(10):S87.Available from: http://journals.lww.com/academicmedicine/Citation/2001/10001/DifficultiesinRecognizingOnes_Own.29.aspx
  6. Edwards R, Kellner K, Sistrom C. Medical student self-assessment of performance on an obstetrics and gynecology clerkship [Internet]. and gynecology 2003 Jan.;Available from: http://ukpmc.ac.uk/abstract/MED/12712114
  7. Haun, Zeringue A, Leach A, Foley A. Assessing the competence of specimen-processing personnel [Internet]. Lab Medicine 2000 Jan.;Available from: http://labmed.ascpjournals.org/content/31/11/633.short
  8. Duffy F, Holmboe E. Self-assessment in lifelong learning and improving performance in practice [Internet]. JAMA: the journal of the American Medical 2006 Jan.;Available from: http://jama.ama-assn.org/content/296/9/1137.short
  9. Kleinpell R. Mirror mirror on the wall: Physician and nurse perceptions of their quality of care for deteriorating patients. Critical Care Medicine [Internet] 2012;Available from: http://journals.lww.com/ccmjournal/Abstract/2012/11000/Mirrormirroronthewall_Physicianandnurse.26.aspx








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  1. Benjamin Squire writes:
    Listened with interest to EMCRIT/SMACC talk on the road to insanity (excellence). While I agree that reading is important, it is only one activity that helps to improve our clinical skills. This made me think about all of the different activities we do that help us to grow as medical providers. I came up with:
    1. direct patient care
    2. supervision of trainees
    3. preparing/giving lectures
    4. sim lab training
    5. reading journals
    6. reading textbooks
    7. writing review articles/textbook chapters
    8. conducting research
    9. QI/QA activities
    10. other medical administrative duties
    11. CME classes
    12. medical conferences

    This is just a partial list of activities that contribute to becoming an excellent clinician. It gets a bit overwhelming.

    I’m interested in hearing how people in various stages of their career have balanced these activities in order to continuously grow their skills. What strategies have been the most successful? What would you do differently?

  2. Hey Scott,
    What’s your workflow for your reading? I’ve been using Read by QXMD (no affiliations) and found it to be really helpful on the ipad

  3. JA Bonk says:


    I thought my list of journals was ridiculous. Yours is lunatic. Do you actually read every article or are you skipping the crap and cherry picking the quality articles (along with reading some of the opinion stuff.) Like Jeff, I’ve been messing with “Read” by QxMD and use an aggregator for online info, but it seems overwhelming. While there is a lot of information, there is also a lot of garbage information. Any useful tips to streamlining information acquisition?

    • I get the TOC emailed to me, which I use solely as a spur to know a new issue has been published. Unlike Cliff and Minh, I don’t read published-ahead-of-print or my life would truly be impossible. Once the TOC comes, I go online and open every article that is related to what I do (many of the journals are in other specialties). I read through the entire article if I found out that it actually is what I thought it was. Always read the editorials and letters to editor as that’s where the juicy stuff gets published.

  4. Minh Le Cong says:

    Hi folks. Thanks to Scott for putting this up and adding the resources. This is an important topic for practising clinicians.

    I dont read textbooks anymore..many reasons but essentially time inefficient, not readily portable ( a colleage of mine used to carry several textbooks in his kit bag on the plane..the flight nurses used to hate it as excess weight!). The main reason is you dont need to read textbooks in traditional format. I have the occasional ebook textbook on my ipad for things like USS..more of a reference rather than textbook reading!

    Reading and discussing topics with peers is for me the greatest way to keep up to date.
    I use PUbMed app to search for key words like intubation, ketamine, sedation, prehospital..scan the search results then find the full text articles using my academic position.

    Research is the other activity that I agree adds to your ongoing professional development. The process and discipline is useful to exercise. there is a lot of bureacracy and crap but you do learn a lot , especially during literature review and presenting your work to peers.

    FOAMEd has expanded my peer discussion globally and asynchronously. Via Twitter I can access peer views 24/7. Via the blogs, I can get a range of peer opinions in various formats. Via the podcasts, I take my learning with me and the discussion.

    I appreciate not everyone wants to do it all..I dont think you need to do it all. choose wisely and find the learning that suits you and is sustainable. If you cant sustain it, it doesnt matter!

  5. GREAT talk Scott – and truly impressive how you have expanded your boundaries beyond being just outstanding clinician and teacher to the philosophical realm of what it really is to teach and to learn. I’m familiar with similar concepts you cite from the Family Medicine literature (Hilliard Jason/Jane Westburg) – where stages in learning/acquiring a skill are 4 in number:

    Stage I – Being incompetent and unaware (colorfully described as being “functionally grotesque” ). You’ve just started and have no clue.

    Stage II – Being incompetent but becoming aware. You’re beginning to learn what it is that you should be able to do – but just can’t yet do it.

    Stage III – Being competent and aware. You know what you should be doing and you are finally able to do it.

    Stage IV – Being Competent but now once again becoming unaware – as you’ve finally become quite good at the skill, to the point that you no longer need to be aware of each step since it comes automatic.

    Being a great teacher means never getting lost in Stage IV. Being a great clinician means never feeling “satisfied” once you’ve attained Stages III / IV.

    THANKS again Scott for a great talk. You are truly inspirational!

  6. Thanks for a great lecture.. I definitely laughed out loud while walking my dog on the section about learning styles. I agree with you completely, regardless of whatever educational paradigm is hot at the moment, learning, knowledge gain, and knowledge retention comes down to hard work, Reading, and practicing (your example of the suturing was spot on).. And your lecture really summarized what I am trying to do with my young career. I want to be an expert one day, and so I know that I need to continuously be learning. To me, simulation is a fantastic way to address many of my needs – allows me to teach, allows me to teach/practice skills, makes me read…

    Another point – I try to constantly challenge myself. I signed up to to do the ACEP new speakers forum to push myself to try to have somewhat of a mastery of GYN emergencies. By signing up, I am forcing myself to read the literature, do a national presentation, and all this with a deadline! Nothing like the potential to embarrass yourself nationally to really get your butt moving and reading!
    Thanks for a fantastic lecture!

  7. John Cronin (@croninjj) says:

    Loved your analogy with the mama-chick feeding pre-digested food!

    Also felt the same way about Cloud Atlas. Great book. Have you read ghostwritten by the same author? Equally exciting and panoramic in its scope.


  8. Scott, thank you. Mastery, from the master. Loved it.
    I maintain my one-handed tying skills every time I take out the garbage. I buy the bags with the drawstring and make myself tie it one-handed. That way I’m guaranteed to reinforce that motor program weekly.

  9. Dan Rauh ACNP says:

    Amazing talk..as usual. I try to keep up with about 1/3 of the journals you do and I can’t do it, you’re an amazing guy. I’m teaching a critical care decision making course for residents and midlevels and I wondered if anyone could point me in the right direction for some nice (somewhat complicated, but not overun with Zebras) critical care case studies. Scott, you still have the standard by which other podcasts are judged! Thanks again.

  10. Nikolay Yusupov says:

    Keeping with the theme of “The Pareto Principle” with regard to the journals. If you had to narrow down the list of recommended books to the top 10 most essential/authoritative list of textbook literature encompassing EM/CC medicine. What will such list entail?

  11. Craig Button says:

    Looking at the Dreyfus model and find it’s remarkably similar to a number of “theories” Benners novice to expert theory. Of course each profession alway things they came up with an idea themselves. :)

    From a nursing perspective, this is one of the failings in basic nursing education. We spoon feed nursing students and they never learn to learn on their own. Both the docs and the nurses think I’m crazy with what I read.

    • Looks like Benner ripped off the Dreyfus folks. Didn’t see her original article, so there may attribution.

      That craziness is what makes you great, Craig.

      • Craig Button says:

        I was actually there in 1980 when they presented the paper. ALthough at that time I had no idea what it meant. I was a lowly enlisted puke at the time reaching USAF Medics.

        They released the paper in 1980 and Benner released her’s in 1984. If you read her later stuff she refers to the Dreyfus model. As I’ve progressed in my education, I’ve found that nursing theorist are basically plagiarizing stuff from someone else. Here lately I’ve found that the term philosophy is a closer match than the term theory. At least when it comes to nursing.

        With the Dreyfus model the only term I have a problem with is the use of intuition. I still haven’t found the word I prefer yet. From a personal perspective “intuition” is the term I use for the willingness to listen to those voices telling you something in the back of your mind, without giving you the clear cut “This is exactly what the problem is”. I was fortunate enough to have good mentors in my career who supported that. One of my first mentors was the Medic version of Leroy Jethro Gibbs. Got the back of my head whacked with a clipboard many times.

        Since then I’ve had the pleasure of working with Pronovost, Lipsett and others who didn’t look down at nurses, and motivated me to at first always know more than the Interns did. So I started to read. And it got to be a habit.

        How does your nursing staff respond to you. Are they motivated ? Or do they wait to be spoon fed?

        • Gabriel Tonkin says:

          I feel compelled to stand up for the importance of “spoonfeeding”. Most of the people reading/commenting here are deep enough into their medical education to have a solid enough foundation to tolerate high level self learning (which is great) but you may have forgotten just how overwhelming drinking from the fire hose was those first few years. A better job spoonfeeding means more total information learned and better retention. I could give medical/nursing students a really thick book chapter with tiny print explaining some aspect of pulmonary physiology and 90% of them will retain 15% of what they read with a 5 hour investment of time. I could also “spoonfeed” the same information to them with a couple of excellent illustrations, some well thought out analogies, and maybe a mnemonic or two, capping it off with some pre and post material practice questions to solidify the learning and they would probably retain 35% of the material with only a 2 hour time investment.

          Students should absolutely be taught/encouraged/manipulated/berated/forced into doing additional self directed learning where they “learn how to learn” but don’t forget that at a basic level there is simply too much material to teach by any means other than spoonfeeding. (& I would argue that during the first 4 years of medical education we could be doing a much better job at spoonfeeding than we already are) Some of the best taught material I got in medical school was during project time when students analyzed and taught a topic to other students and the professors just sat in and performed an advisory/fact checking role. I both performed and received some excellent spoonfeeding during these times.

          • @ Gabriel – I agree with much of what you write – but I think there has to be a middle ground between “spoonfeeding” the learner and getting the learner motivated to do some learning on their own. I’ve given courses where the more I spoonfed – the less the learner wanted to learn on their own (and the more critical they became of “not being spoonfed enough”). Finding that optimal “middle ground” is the art of excellent teaching.

          • CraigButton says:

            I guess the issue here is more our individual definition of spoon-feeding. As a person who has taught everything from basic EMT to clinical sessions for residents, I have a personal definition that basically boils down to. Spoon-feeding = Teaching to the test. Giving the students what they need to pass the TEST not necessarily be good providers.

            And yes some of the basic levels of information have to be handed to the students in small bites. But they should be foundational knowledge. Once the foundation is laid, then they should be able to build on their own.

            As those nurses and the pulmonary physiology? Well they need to start with the right book. Are you trying to make them Dr’s or just better nurses. If your trying to make them better nurses, how about an RT book. A group of motivated critical care nurses will learn what they need to know and will also take home a little extra knowledge.

            The hard part as an educator is finding the balance that works best for both the program and the individual students. It also depends on the subject and were they are in the program. Spoon-feed more in the beginning and move to guiding them into learning themselves as the program moves along.

            p.s. I learned to 1-hand tie just so I could show off. Left lots of nylon hanging off doorknobs. Athough if my old arthritic fingers tried to do it now, I’d be tied to the door knob.

            • Gabriel Tonkin says:

              Point taken about the definition of spoonfeeding. If by “spoonfeeding” you mean teaching to the test, than of course I am against that (except in those instances where it is a bad test and they try and ask you something useless like what is the drug of choice to treat hairy cell leukemia)
              I guess I am defensive because I have had bad professors and bad attendings use “I am not going to spoonfeed you” as an excuse to not teach well, or not teach at all. Medicine is so very complicated that pre-digesting the material at the beginning stages is a necessity if most of the relevant material is going to be learned. To borrow from Hippocrates: “Life is short, and the Art long; the occasion fleeting; experience fallacious and, judgment difficult.”

  12. Seth Trueger says:

    Great talk!

    Re: using the Pareto principle to efficiently read: you’ve articulated one of the main reasons I use twitter. I always thought of it as a “moderated RSS feed” with all sorts of experts curating journals and directing me to the best papers. It’s not just picking the highest yield 20% of journals – it’s (theoretically) the best 20% of articles across “all” journals.

    And, for what it’s worth, I learned how to 1-hand tie (left handed so your right hand is ready for the next bite) on my OB rotation in med school – and I practice on garbage bags, too – I close many more garbage bags at home then secure central lines at work

  13. Does anyone have any suggestions specifically as to how I can access the full journals that Scott was talking about. No way I’m getting through as many as Scott but would like to start reading the top 12 he recommended. I’m not about to pay 300$/yr for subscriptions for each journal. Is there anyone who is reading these journals found a way to read the journals at home without paying the astronomical $?

  14. Sorry to bother with a minor question, but I’m looking for the information that refutes the theories of different learning styles. You had commented that it would be on your site, but I could not find the citation. Am I missing something?

  15. Juliet Carrington says:

    Great lecture, as are all of the lectures you present or endorse. I work in the HEMS industry and feel many of your talking points can easily transfer into pilot and crew safety. I will be sharing some points during future safety presentations. Thank you again!

  16. Scot,

    When you were researching the Dreyfus model did you come across any studies.papers that support the stat that most people never get beyond the advanced beginer stage. I’ve found graphics but having a hard time finding reputable source documents.


  17. Scott, thanks so much! So much of the info you talk about can be applied across different medical fields. I am in paramedic school right now and find myself working through different stages and found myself wondering if it was just me or just part of the progression. The more I learn about medicine the more I find myself wanting to know yet there are days I truly feel like I don’t know a thing or get the feeling that I am lost in the abundance of information. I listen to the podcast regularly, great stuff! Thanks again..

    • Thanks for listening Ian! Hang in there and know that when you feel like you know everything it is time to retire as you’ve become delusional.

  18. Mastery is perhaps the most important book I have ever read. Loved Mastermind too. Enjoying the articles about effects of meditation. Can you recommend a concise how to meditate source that isn’t some annoying guy trying to sell me something?

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