“The most commonly missed fracture in emergency medicine is the second one.”
-Pat Croskerry, MD, PhD
Croskerry’s research describes many types of cognitive pitfalls in medicine. Many of them have to do with how we perform in a state of search. Failing to notice a patient’s second fracture is one such type, known as search satisfying error: “the universal tendency to call off a search once something is found.”
I’m interested in this tendency to come to conclusions too early – this very human impulse to call off our searches. We all have it, for good evolutionary reason. And it’s a broad factor in errors across fields, not just in medicine (though it’s particularly costly and sad in medical situations). Search satisfying is not the only error in search.
The urge to satisfy our searches is what drives innovation and advancement, but it also has a shadow. Poor management of this impulse is often the cause of mistakes. Mistakes in cognitive dispositions to respond are particularly hard to address because they are both prevalent and complex.
Recently, Danielle Ofri, MD, bravely wrote about her own too-quick scanning of a situation, resulting in a patient’s intracranial bleed. I applaud her open description of how she lapsed in a state of search, when most would keep it silent in shame. This is the kind of leadership that helps cultivate environments of learning from, and preventing, mistakes–environments where patients, families, and caregivers alike can all be better in a state of search.
My own training in art-making and in art museum education has given me insight onto the issue of professional performance in a state of search: our searching is connected to our seeing. We look differently at things that we understand and at things that we acknowledge we do not yet understand. The latter is how an artist looks at the world. Artists have literally trained their eyes to be separate from their judgment. Artists depend on, and actively cultivate, openness in their looking. This almost childlike newness (or fresh eyes) is at the heart of arts practice – and something that can be emulated in art-viewing experiences (the Visual Thinking Strategies method directly builds in similar habits of open-minded engagement. (I’ve been working on adapting the VTS training model to issues in healthcare, and just completed a yearlong pilot with clinical faculty. Contact me if you would like a copy of the report.)
When we look, we see. And when we fail to update our seeing with looking…that’s when the truth gets lost.
I’m super interested in how experts across fields hold an element of beginnerness and openness in their looking, no matter how smart and experty they are. In fact, I think it’s the hidden marker of true expertise that no one learned in school (though they might have had to go out of their way to un-learn some of the search-habits they were taught there). I have worked with educators across fields in the health professions who help students cross the bridge from training into practice (transitions not known to be easy). They all lament the same thing: students who are not in touch with the reality of uncertainty prevalent in science, in the clinic, and in life.
At a time of rampant misdiagnosis and shifting dynamics in medical decision-making, isn’t it time we made it safe for all of our learners to get better in states of search?
This post reflects some of my remarks at the recent symposium Millennial Medicine: Knowledge Design for an Age of Digital Disruption, Rice University/Baylor Medical School. Watch video footage of the talk – and many others far more interesting ones! – here.
On October 25-26, I will be holding a workshop for clinicians based on these ideas. Learn more about this and other upcoming workshops here.
