The Lesser “Personal” Side of Medicine

A century-old tidbit of wisdom from the Book on the Physician Himself by DW Cathell MD (published way back in 1902, so ignore the pronouns):

EVERY Medical Man discovers sooner or later that The Practice of Medicine has two sides: A Greater Scientific Side, and a Lesser, but important, Personal Side, and that to fight the battles of life successfully it is as necessary for even the most scientific physician to possess a certain amount of professional tact and business sagacity as it is for a ship to have a rudder.

Only one of these sides is meaningfully taught or modeled in school, and I think we’ve all met physicians who do not seem to possess “professional tact” or “business sagacity” and been worse for it. Cathell was writing during a time when most physicians literally were one-man shops, but if anything the “lesser” side of the Practice of Medicine is more important than ever.

Discussing the ancient pro/cons of specialization that led to ever-increasing specialization over the next 120 years:

You may also ask the question: Shall I adopt a specialty? Would it pay me to do so? The adoption of a specialty, to the exclusion of other varieties of practice, is successful with but a few of those who attempt it. It should never be undertaken without first studying the whole profession and attaining a few years’ experience among the people as a general practitioner.

A successful specialist has many advantages over the hurly-burly life of the general practitioner: He is independent of general practice. He has short hours and is seldom or never called out at night. He can escape the expenses of horses, carriages, stables, and drivers. His Sundays are his own if he chooses. His fees are always good, sometimes fat. He can tell his terms and arrange about the payment of his fees at the beginning of each case, and usually gets them cash, and after a much easier life he generally dies a great deal better off pecuniarily than the general practitioner.

On the other hand, the specialist must be better equipped in instruments, etc., and more dextrous and masterful in their use and also more concise in the details of treatment; should possess a faultless manner and must foster his practice more carefully; in other words, if you put all your eggs in one special basket you must watch that basket much more closely.

So much energy has been spent fighting in the turf wars of watching and growing those special baskets that doctors dropped the ball on the broader healthcare basket entirely.

Dying rich after an easy life sounds nice, but he did miss the part where the physician became an employee and stopped being able to choose those short hours and Sundays “as his own.”

(Hat tip @archives_Rx.)

Getting Started in Radiology

Here’s a little compilation of posts from the last few years about getting started as a new radiology resident.

Doing

Approaching the Radiology R1 Year and its short companion post: How to be a First-Year Radiology Resident.

Want something a little more controversial? Stop Free Dictating.

Learning

Book Recommendations for First-Year Radiology Residents (and some further recommendations for when there’s extra book fund to burn).

You can round that out with some more general thoughts on studying during residency.

Also, residents from across the country in the ACR Resident and Fellow Section came together and assembled a nice collection of free radiology learning resources from across the interwebs including lots of videos.

 

The Limitations of Copy and Paste

From “To Kickstart a New Behavior, Copy and Paste” by Kathy Milkman, author of the new book, How to Change, which suggests the best way to master a new skill is to emulate the methods of someone successful.

Happily, it’s easy to turn yourself into a deliberate copy-and-paster. The next time you’re falling short of a goal, look to high-achieving peers for answers. If you’d like to get more sleep, a well-rested friend with a similar lifestyle may be able to help. If you’d like to commute on public transit, don’t just look up the train schedules—talk to a neighbor who’s already abandoned her car. You’re likely to go further faster if you find the person who’s already achieving what you want to achieve and copy and paste their tactics than if you simply let social forces influence you through osmosis.

Kinda maybe sorta.

There is a big, big difference between emulating psychosocial habits (like vegetarianism or fashion) or noncomplex skills (like a workable commute route or some forms of regular exercise) and achieving success in a skill-based habit like practicing medicine or playing an instrument.

For low-stakes or low-commitment behaviors, sure. It’s reasonable to try to save time and give yourself the boost of something that has worked for someone. Copy-paste saves you from analysis paralysis.

But copy and paste is also a guaranteed way to fully embrace survivorship bias. You don’t know if the people you are emulating succeeded because of their methods or despite them. You don’t know if those methods are optimal for you or if the most important aspects of said methods are even those which are externally visible or consciously retrievable from the expert.

A lot of people don’t know why they’re successful, and their attempts to craft a narrative about their successes are fiction.

And when it comes to experts instead of peers, one of the common difficulties for many is that it’s been so long since they’ve been a novice that they literally don’t know what it’s like anymore. Their memories of their early growth are fuzzy and often out-of-date to boot.

As we are back in the middle of USMLE Step season for the medical students among you, I am reminded of this post I wrote in 2014 about the Methods to Success Fallacy.

Being “Backable” for Residency Interviews

After reading stories of match success and failure on social media this spring, I’m already thinking about another set of virtual interviews this fall and contemplating how applicants can shine.

Here are some takeaways from Backable: The Surprising Truth Behind What Makes People Take a Chance on You. While this book and its many examples mostly center on entrepreneurship and how startups can get money from investors, there are some nuggets that cross domains nicely. The interview is in some ways a pitch meeting where you’re selling yourself.

The power of unique perspectives and experience

[Investor Ben] Horowitz responded that great ideas typically stem from an “earned secret”—discovered by going out into the world and “learning something that not a lot of other people know.”

Everyone says the same things in personal statements, is drawn to their chosen fields for the same reasons, and has largely similar clinical experiences. When you have rare real-world experience–frankly in any context or domain–that makes you different.

Share how those insights have changed you and inform your approach to medicine.

Earned insights are rare

What’s the single best piece of advice that would help them succeed?” [Oscar-winning producer Brian] Grazer paused for a moment, then said, “Give me something that isn’t google-able. I want an idea that is based on a surprise insight. Not something I could find through a Google search.”

An idea that stems from hands-on experience is way more backable than the same exact idea if it simply originated sitting behind a desk. But the catch is, without being boastful, you have to make that effort shine through your pitch. It can’t be hidden.

Here’s an open secret: a few months of clinical experience don’t make you an expert in your chosen field just as even less time in other specialties doesn’t make you an expert in those either. Bringing fourth-year swagger to interviews often isn’t a great idea.

That said, real insights–whether about your specialty, health care, or even just being a human being and having a good attitude about showing up to work every day for your patients–are a breath of fresh air. I love when I can tell an applicant has an active mind and thoughtful approach, when I can really see their gears turning.

Why should someone be scared to miss out on you?

As creators, our job isn’t to use FOMO to manipulate backers, but rather to neutralize their fear of taking a bad bet. Though it may sound strange, FOMO can make a risky bet feel safe because it shields us from the risk of being left behind. This feeling of inevitability rarely comes from the argument that we should change the world, but rather from the argument that the world is already changing—with or without us.

If there’s a knock on your record and you’re scared people are going to pass you over, own it. The typical advice is to talk about what you learned after your failure, how you’ve changed, and other such bland platitudes, but the fact is that I expect anyone who has messed up to tell me they’ve grown.

That’s all fine. Go ahead and do that.

But…don’t just approach your candidacy from a position of weakness. What about you is unique or special? Why should a program director be scared to lose you? Why are you backable despite (or because of) that setback?

Connections are powerful

Salman Rushdie once wrote, “Most of what matters in our lives takes place in our absence.” While we’re present for the pitch, we’re most likely absent for the hallway huddles, backroom meetings, and email threads that decide the fate of our ideas. Backers become fierce advocates when they are on the inside of an idea. They crack their own egg and add it to the mix.

Stronger-than-average connections with your interviewer will cause people to go to bat for you in the post-interview huddle. So many interviews are bland Q&A. True connections are rare. If you can get an organic discussion going and the time flies, everybody wins.

Each interaction is an independent variable

We don’t typically win people over in one conversation, but through a series of interactions that builds trust and confidence. Even if the last conversation went poorly, you can use the next one to show them how they influenced your work. This type of follow-up is so powerful that it can often change a backer’s response from no to yes.

You can’t really do this with your interviewer (post-interview correspondence doesn’t carry that kind of power), but you can take each interview as a fresh start.  Don’t let one sour interaction spoil the day.

Interviewing is a skill that requires practice

We’ll spend hours researching, outlining, pulling together slides—but very little time practicing what we’re going to share. The feeling seems to be that if we have the right content and we know it well enough, then there’s no need for practice. But I’ve found that backable people tend to practice their pitch extensively before walking into the room. They practice with friends, family, and colleagues. They’re rehearsing on jogs with running partners, in the break room, and during happy hour. They prepare themselves for high-stakes pitches through lots of low-stakes practice sessions—what I now call exhibition matches.

You need to practice. The common approach is to do practice interviews, often with residents and faculty at your home institution (and potentially online organized on social media). You should do those things.

But I’d take it a step further.

You should talk to strangers. Practice having genuine interactions and conversations with people who don’t know you.  Practice really listening to your patients. Get to know them as the three-dimensional human beings they are.

The easy flow of conversation is a delight to interviewers.

You are a process, not an outcome

The other techniques in this book got me comfortable with content, but I still had to learn to get truly comfortable with myself. I had to learn to let go of my ego—to express, rather than impress.

So much of your identity feels tied to your success in school, the match, and your developing career as a physician. But internal validation is always superior to external validation. You don’t and can’t control outcomes. You–at best–control yourself and your approach.

You will enjoy and likely be more successful in the match process if you are content with yourself, happy to do your best, and try to find a good fit. We call it “practicing” medicine, but living life is also the practice of showing up each day working on being the version of ourselves that we strive to be.

When you receive an interview, your goal is not to impress your interviewers. It should be to express yourself and be open to others so that you can find the best place to live and grow in your practice.

Shallow versus Deep. Prolific versus Profound.

From Rest: Why You Get More Done When You Work Less:

We see work and rest as binaries. Even more problematic, we think of rest as simply the absence of work, not as something that stands on its own or has its own qualities. Rest is merely a negative space in a life defined by toil and ambition and accomplishment. When we define ourselves by our work, by our dedication and effectiveness and willingness to go the extra mile, then it’s easy to see rest as the negation of all those things. If your work is your self, when you cease to work, you cease to exist.

What fraction of doctors (and miscellaneous business workaholics) do you think still believe rest is for the weak and that the ability to slog and hustle is not just good but truly enviable?

Second, most scientists assumed that long hours were necessary to produce great work and that “an avalanche of lectures, articles, and books” would loosen some profound insight. This was one reason they willingly accepted a world of faster science: they believed it would make their own science better. But this was a style of work, Ramón y Cajal argued, that led to asking only shallow, easily answered questions rather than hard, fundamental ones. It created the appearance of profundity and feelings of productivity but did not lead to substantial discoveries. Choosing to be prolific, he contended, meant closing off the possibility of doing great work.

Just like many jobs are bullshit jobs, much of our research is bullshit research. If we reward volume, we disincentive depth.

As Vinay Prasad was quoted in the Atlantic, “Many papers serve no purpose, advance no agenda, may not be correct, make no sense, and are poorly read. But they are required for promotion.”

When we treat workaholics as heroes, we express a belief that labor rather than contemplation is the wellspring of great ideas and that the success of individuals and companies is a measure of their long hours.

And this is one of the tough parts about almost everything written about deep work, rest, the power of no, when to say yes, and everything else in the modern business/productivity/self-improvement genre. The approaches just don’t apply very well out-of-the-box to service workers.

Doctors are primarily service workers. If we work more hours, we see more patients. While there is almost certainly a diminishing return in terms of quality care, there is no diminishing return for billing. A doctor generates more RVUs when they have more clinical hours, and that means more profits for their handlers (until someone burns out and quits).

William Osler advised students that “four or five hours daily it is not much to ask” to devote to their studies, “but one day must tell another, one week certify another, one month bear witness to another of the same story.” A few hours haphazardly spent and giant bursts of effort were both equally fruitless; it was necessary to combine focus and routine. (He lived what he preached: one fellow student recalled that in his habits Osler was “more regular and systematic than words can say.”)

Cramming is bad. Overwork is bad. A reasonable concerted effort over a long period of time is good.

Studying 4-5 hours a day was apparently a reasonable amount to Osler’s sensibility. Olser, if you recall, founded the first residency training program at Johns Hopkins.

Do you remember when the heads of the NBME and FSMB suggested in 2019 that a pass/fail USMLE Step 1 would be bad because students might take the decreased pressure as an opportunity to watch Netflix? Because I do.