This was my favorite lecture assigned to me at SMACC 2013. It discusses the search for excellence in our profession. I hope you enjoy!
Knowledge
The Pareto Reduction to 12 for EM Critical Care
- 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.)
Read Outside your Specialty
from Mathieu Brunet
More
- 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
- The 10,000 hour rule is essentially bullshit
- Mastery on the Doist Blog
Procedures
More
- Siamak Moayedi has one of the best lectures on procedural knowledge. The lecture is now available in video form as well
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
More
Thinking Fast and Slow by Kahneman
Potholes
Dunning-Kruger Effect
- Kruger J, Dunning D. Unskilled and Unaware of It: How Difficulties in Recognizing One's Own Incompetence Lead to Inflated Self-Assessments. Journal of Personality and Social Psychology 1999;77(6):1121.
- Dunning D, Johnson K, Ehrlinger J. Why people fail to recognize their own incompetence. Current Directions in 2003 Jan.;Available from: http://cdp.sagepub.com/content/12/3/83.short
- 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:
- 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
- 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:
- Difficulties in Recognizing One's Own Incompetence: Novice Physicians Who Are Unskilled and Unaware of It [Internet]. Academic Medicine 2001 Oct.;76(10):S87.
- 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
- Haun, Zeringue A, Leach A, Foley A. Assessing the competence of specimen-processing personnel [Internet]. Lab Medicine 2000 Jan.;Available from:
- 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
- Kleinpell R. Mirror mirror on the wall: Physician and nurse perceptions of their quality of care for deteriorating patients. Critical Care Medicine [Internet] 2012
Meditation
- 23408771
- 21071182
- 16272874
- http://faculty.washington.edu/wobbrock/pubs/gi-12.02.pdf
- http://dx.doi.org/10.1016/j.brainresbull.2011.03.026
Update
- Want even more along these lines? Watch this amazing video on developing clinical judgment by Gurpreet Dhaliwal
- The_Nature_of_Excellent_Clinicians_at_an_Academic Medical Centers
- Dhaliwal on Excellent Clinicians
Additional New Information
More on EMCrit
EMCrit 182 – Kettlebells for the Brain – Meditation
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit 383 – The Ultrasound Hierarchy of Needs in Cardiac Arrest with Mike Prats - September 6, 2024
- EMCrit RACC Lit Review – September 2024 - September 3, 2024
- EMCrit 382 – A Deep Dive on Vasopressin: Timing, Push Dose Vaso and the Vasopressin Load Test - August 23, 2024
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… Read more »
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
Scott,
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.
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… Read more »
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… Read more »
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… Read more »
Sounds like you are on the path!
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.
Thanks
John
John, I’ll check it out right now.
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.
that is fantastic!
Bill – I’m glad I’m not the only one who practices tying with the garbage drawstrings 😉
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.
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?
recommended reading is on the side-bar of the blog site
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.
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… Read more »
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… Read more »
@ 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.
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… Read more »
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… Read more »
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… Read more »
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 $?
Rich, we had a discussion on this on the G+ page emcrit.org/plus
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?
Hi Stuart, the study can be found here:
http://psi.sagepub.com/content/9/3/105
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!
thanks, Juliet!
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.
Thanks
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.
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?
this is my recommendation
Wow! Remember when I first heard this while in the first clinical years of med school. Sorry for a late and long post, but I have been reflecting about this specific talk since I first heard it, and have some sincere questions. I am now in my last year of med school (6 year medical program) and have been increasingly puzzled about how to approach “insanity”, and whether it is worth it or not. Most of all, I wonder about the timing to start to try becoming insane. During the pre-clinical years of med school, I struggled hard to try… Read more »
Pareto is the way to go. If you scale back to 20% you will still excel and reach mastery, but you are able to have hobbies and free time.
Hope so, but does that really make sense? How can you become a master when you are putting just as much effort, or maybe even less, than everyone else? What happened to all your residents?
don’t understand the ?