Connecting the dots: like watching a movie…critically

It was not always clear to me that I was going to follow the path of Internal Medicine. Having witnessed the miracles of cardiovascular surgery that saved my father I entered medical school determined to be a cardiovascular surgeon. It took a few sessions in the course of medical semiology (the study of sign and symptoms) for me to become enraptured with the power of the history of present illness and the physical examination and its relationship with underlying pathophysiology. Progressing into the clinical years of medical school provided me with countless moments of awe in witnessing first hand the power of clinical reasoning.

“This patient does not have tuberculosis” declared the master clinician, interrupting the presentation by the junior resident while he was reviewing the chest-X-Ray. The patient was a young man referred to the University Hospital, a small and under resourced institution in a third world country, where obtaining a PA and lateral chest X-ray was a luxury. The patient under discussion had recurrent hemoptysis and a right upper lobe lesion that had been treated with two different anti-tuberculous regimens over the last 18 months without resolution of the hemoptysis or the radiological abnormality. The master clinician reasoned that the lack of fever, night sweats or weight loss, the smooth radiological appearance of the lesion, and the perplexing small purplish dots around the nails could be better explained by a non-infectious etiology. His suspicion was confirmed when an arteriogram revealed an arteriovenous malformation of the lung confirming the diagnosis, made at the bedside, of hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber). How was this clinician able to connect seemingly unrelated pieces of information into an elegant diagnosis? How did he avoid the cognitive biases that had plagued our whole team and many other physicians from the referring institution? When asked these questions he simply answered: “the difference between all of you and myself is that I have seen this movie many times so I understand its plot better than you can at your stage of training”.

The master clinician, unlike the rest of team, had approached the case with an open mind, ignoring the reason for referral. Prior physicians and the team had fallen into the trap of the representativeness heuristics as the radiological lesion and the persistence of hemoptysis made tuberculosis, a rather prevalent condition in this country, the most “representative diagnosis”; diagnostic momentum clouded the thought process in terms of explaining the components of the evolution that did not fit this diagnosis (lack of fever or weight loss). The master clinician not only circumvented these cognitive traps [1] but also linked the periungual lesions to the rest of the information provided seamlessly and within few minutes into the presentation. In today’s cognitive parlance he appeared to be using System 1 processing [2]; most of my esteemed colleagues would be laboring to arrive at such a diagnosis making use of System 2 processing. This display of expertise was rare amongst our wonderful teaching faculty but was exhibited with astonishing frequency by this professor. He avidly read the medical literature, was on ward attending rounds every month, and reviewed both films and tissue pathology obtained on his patients. He had adopted reflection-in-action and reflection-on-action behaviors [3] making him a true expert amongst his colleagues. He had indeed seen critically many such movies during his professional career.

As a practicing general internist and clinician educator I have a great deal of interest in trying to understand how expertise can be acquired and how clinical reasoning can be taught. For many years I have followed the cognitive and decision making literature yet still find this “watching the movie” metaphor the best explanation of why it takes years of reflective practice to become adept at “connecting the dots”. The day I heard the movie metaphor I had an epiphany reflecting on my sense of confusion and frustration after first watching movies such as Bergman’s “Cries and Whispers” or Fellini’s “Satiricon”. Suddenly the statement of the master clinician made perfect sense to me; after watching carefully the same movie, or disease entity, patterns start to form and subtle sentences and frames take a different meaning. The nuance and subtle monologues and dialogues in the movies take a different form and the complex plot takes on a life of its on, invariably rich and fascinating. It is this repeated exposure to clinical reality, carefully reflected upon under guidance [4], that has both led to what expertise I have attained and to an appreciation of the struggles of my learners as they grapple with the complexities of clinical reasoning.

Over the years I have spent countless hours trying to decide what I can offer to my learners. Since residency I have utilized a Socratic teaching method on the wards, in the ambulatory clinic, and in small group conferences. I have done so because I patterned myself after my “heroes”, who used this style of discourse when explaining their thought process when linking pathophysiology to the history of present illness or the physical examination. On recently seeing Dr. Tinsley Harrison’s aphorism: “If knowledge is what you seek then go and read my textbook; I’m here to teach how to take care of patients” I realized that I was imitating one of my heroes. From a learner perspective we have discovered that what students and residents appreciate the most is having us “open our minds to explain our thought process” [5]. In a way, our learners are telling us that it is quite difficult for them to understand what they are being exposed to for the first time as clinicians. The uncomplicated pneumonia patient for a second year medical student – the decompensated cirrhotic to a third year medical student – a puzzling CBC in a patient with immune hemolysis for a seasoned third year resident: in each of these instances the learner is being exposed to a new entity, which feels like “Satiricon” felt to me when I first watched it. The most seasoned and respected clinicians in our institutions have not only seen the same patient time and again but have also made great efforts to continue to improve themselves by learning from their mistakes and shortcomings. While exposure to a large number of varied patients is essential it would not be sufficient if we did not reflect on our performance. It is this cumulative experience that allows seasoned clinicians to ponder and question when “data does not fit” [6] or seemingly unconnected dots can indeed be related to one another [7]; by now we have learned both to expect the unexpected and to not be frustrated with the unknown. Years of trial and error have shown us that every clinical encounter might represent a new movie style (e.g., Matrix or Inception) and as such we are cognitively prepared to learn from such a movie with the understanding that careful observation and reflection will likely help us understand this new theatrical adventure.

Being fond of aphorisms I would like to capture the essence of what I believe is my principal role as an educator by quoting what Socrates stated over 2000 years ago: “I cannot teach anybody anything. I can only make them think”. Clearly what we do on our wards is more complex than diagnosing a “disease” and we must never forget the importance of compassion, respect, and caring as fundamental aspects of who we are; however, as I continue to struggle to better communicate my immutable sense of awe for clinical reasoning, the images of my old professor using cinematography as a metaphor remains a useful one.