We often underestimate the influence that our environment has on our decision-making.
This week, in the middle of an education session, I was interrupted by the ‘clicking’ of a little gecko. He was lurking outside my study window, feasting on the myriad of insects inhabiting my fernery. And then there was some different clicking. It was coming from my colleague’s study, via Skype. The two little lizards continued chatting for a while as the other doctor and I shared a conversation about how unique that was.
Acknowledging the importance of ‘background noise’ and how it contributes to our synthesis of information, is critical when approaching assessment. Assessment by its nature, is designed to mitigate against gut feel and background noise to ensure the results are valid and reliable.Whether it be in our day to day activities or in our clinical practice, there is always background noise, that can at times be distracting, but can also be informative to our decision-making. In a consultation, we aren’t just taking a history, or performing an examination, we are assessing the vocal tone and mood of the patient, looking for a grimace as we examine them, thinking about how we saw another patient that day with similar symptoms, and wondering how our current patient is coping with their recent marital problems. We are aware of what illnesses are ‘trending’ in the community, and in social media, and can sense the nuances of an unmet agenda in the consultation. We notice all the little things, acknowledge our ‘gut feel’ and combine these with our clinical acumen to define the diagnosis, make a plan and safety-net.
Exams are different – we are diagnosing in a vacuum.
When we are posed with a question in a written exam, the only information we have to make a diagnosis is the words on the page, and the illness scripts in our head. We can’t see the patient in front of us, we don’t know the prevalence of illness in our ‘on paper’ community, and we can’t see the non-verbal cues expressed by the patient as we take the history. What this means is that we must make sure that we consider absolutely all of the key features in the question, because if we jump to conclusions, or pattern recognise, there are no environmental cues to tell us we are on the wrong track.
So how do we make sure we are recognising all of the key information? In the written exams, when you read the stem of the question, read it twice. Then generate a differential list. If you can’t generate a decent differential list, consider Murtagh’s masquerades, use a surgical sieve, try a system-based approach and consider the Domains of practice. For each patient that you see, try and take the same approach. If you can’t generate a differential, then it is likely that you are pattern recognising or are lacking content knowledge in that area. In exams, read the stem twice, then commence the questions. When you are checking your answers, ask yourself how the historical feature/examination/investigation helps you to rule in or out your diagnosis. Check that the features you have listed actually relate back to the differentials that you have generated. If there is a mismatch – why is this so? Are your differentials to narrow, are your answers off track? Is there a clinical bias creeping in to steer you off track?
In the OSCE, use your reading time to picture the scenario. When you enter the room, try and gain clues from the environment, just as you would in a ‘real consultation’. Yes, we are role playing, but we are role playing non-verbal cues and emotions so don’t ignore those. When you are discussing management, imagine yourself in this exact consultation in your practice, and manage as you would there – your answers and communication style will be more comprehensive and authentic.
I encourage you to consider your environment in your study too. Think about these environments:
- Clinical environment – Consider your patient demographic profile and how it influences your interpretation of factual knowledge. Are there a subgroup of patients that you don’t see? Why is this? How is your knowledge in this area? How can you address this contextually? (i.e. not just revising extra on that topic?) Perhaps you could sit-in with a colleague who sees a different patient demographic to yours.
- Mental environment – How realistic is your study timetable? Have you scheduled in some personal time and actually given yourself permission to recharge your batteries? Are you distracted when you are studying? Do you have study fatigue and how might you address this? Schedule ‘you’ time in your study plan.
- Physical environment – Where are you studying? Are there interruptions? Do you have a comfy chair? Could a change in your environment be useful? e.g. Sit under a tree, go to a local library etc.
- Learning environment – Are you learning efficiently or are you just going through the motions? Is the way that you are learning congruent with your learning style? If you don’t know your learning style, have a look at the VARK Learning Questionnaire. Learning that is not interesting is not effective or sustainable. If you’re looking for a way to make your study (or teaching) more interesting, then take a look at the GP Study (GPS) System which facilitates contextualisation of knowledge within your clinical environment.
Meeting a patient’s agenda is so much more than putting key features into a decision-making tool to ‘spit out’ a diagnosis – otherwise we would have an App for it! By considering what information you use to generate a diagnosis, and your clinical biases, you will be able to approach GP assessment and your clinical practice with more clarity and safety. Notice the little things, and listen for the geckos!