Monday, August 22, 2022

Ikigai and What It Means To Be An Expert

Lost and Afraid
I was feeling lost for quite awhile. The frightening thing of not knowing what else can be done. I had studied to the point of burnout and revised the entirety of the syllabus before attempting the OSCE – and still failed. Studying harder is not the solution.

But I think im starting to get the idea of what this exam is all about.

After gaining the necessary book knowledge (passing the primaries, and fellowship writtens), the final textbook/syllabus is REAL LIFE, with the development of structure in active working memory and heuristics to respond to unique circumstances.

It sounds impossible. But put it this way: It cannot break the rules of real life. There is only so much that can be examined realistically in an OSCE scenario.

How do you prepare for an exam that doesnt really have a textbook or syllabus?
An exam that tests if you are functioning at the level of a consultant. Looking back, my approach was completely wrong – book knowledge will not get you past this exam. You could say all the right things, yet lose marks in Prioritization, Leadership and Communication. 

One revelation came when I got a zoom account and recorded some practice OSCE sessions. It’s hard to describe, but I was speaking like a registrar – not a consultant. Rewiring my brain will take time and practice.

Standing in front of each OSCE station, there is a stem. A spiel. A clinical situation. An expert knows the meta/background of the clinical situation, and will be thinking three steps ahead – what needs to happen, what to look for, and important organizational minutae that needs to happen.

A second revelation came from a very senior, recently retired, ED consultant (James Taylor) who gave the following words of wisdom:
It is a Specialist Level Expert Exam. It is designed to blow gaps in knowledge apart, and assess your response to very specific scenarios that require expert level knowledge and input. 
- Contents unchanged for past 30 years.
- Ask how am I going to be an expert at: (insert oddly specific thing here)?
- budget 20hr/week for 50 weeks.
- Take time. Read your books. Know the drills.

You will know you are ready when you can confidently answer the following questions:
- Am I functioning at a registrar level or expert level?
- Are there clear improvements in Markers of progress?
- Am I Well prepared – 1000 hours, courses, and trial exams?
- Do my mentors think I am at expert level?


How I Failed?
Change in hospital. Lost touch with mentors. Lost sleep / circadian rhythm. Slept for two hours the night before the exam (anxiety). I did not have enough practice, and only found out about the old SCEs four weeks out to the exam. Completely wrong study approach. Going through the entirety of a syllabus did not help me prepare for this exam. Studying harder is not the solution.

SWOT analysis
Discipline and work ethic.
Experience of real exam, and multiple trial exams and many months of practice with mentors. I am starting to get the vibe of what I need to to – develop expert level heuristics.
Stacked repetition of previous experiences will make learning a whole lot meaningful.

Near zero empathy and low emotional intelligence.
Writtens in March 2021 – need to refresh knowledge.

There is time to organize and structure approach. 
Time to attend more courses.
Need to pass by 2026. There is time.

Failing kills confidence – second attempts have a lower success rate.


What It Means To Be An Expert.
(link to Veritasium’s video here)

TL;DR - Expertise = Recognition = Intuition.

There are two memory systems that we use daily: System 1 (fast, subconscious) and System 2 (conscious slow effortful). Think riding a bicycle vs carefully considering which stock to pick.

Better working memory for specific situations that occur in real life. With full pattern recognition / chunking - making sense of complex situations quickly and seamlessly.

Having highly structured information stored in long term memory. 
Need to be able to quickly assess a clinical situation (or OSCE stem!).

1. Many repeated attempts with feedback - This is the osce process, which is why it is a finishing school of sorts for consultants.

2. A Valid Environment - Immerse self in an environment where the specific situations can occur. Where feedback actually means something on a deep level. This means working full time, and having lots of interaction with senior mentors who have a wealth of practical knowledge not in any textbook. 

3. Timely feedback - real life feedback is ideal, but rarely happens on the floor. The OSCE training process is essentially a virtualization of clinical encounters with timely feedback.

4. Deliberate practice in challenging situations. Dont get comfortable - I have become competent in most clinical situations. That does not make me an expert. It causes stagnation and prevents that extra learning that is required to become an expert. I need to immerse myself in to complex clinical situations until it becomes second nature to sort them out.

It is pointless to 'study' for the OSCE. The key to passing is not in any textbook or reference manual. I need to meet the four criteria above to develop a structure for approaching common and uncommon (oddly specific) situations that I may have never seen in real life.

Common situations would be things like:
- a pediatric elbow injury
- diabetic complications (HHS / DKA).
- a myocardial infarct.

Uncommon situations that I may have never practiced in real life such as:
- managing a priapism
- system crisis (external emergencies / fire / access block)
- managing a smallpox/contagion outbreak
- dealing with workplace interpersonal conflicts.


Learning 2.0 
– In my 36 years of life. This is what I think works best.

1) A Healthy State of Mind
- Enough sleep. At least 7 hours a day.
- Enough exercise. For enhancing neuroplasticity.
- Enough nutrients. Fish twice a week at least.
- Enough social contact. I must not neglect my friends.

2) Stacked repetition
- The single most important thing to ingrain things to long term memory. Repetition at intervals.
- Perform. Polish. Perform again. Polish. Until second nature.
- Think Karate Kid.

3) Reliable Sources of Wisdom
- Wisdom, not just knowledge. Structured. Curated. Distilled.
- The structure that has been developed in senior consultants
- Templates from which I can grow my own structure.
- Regular meetings with my mentors, consultant examiners, and peers.

wax on, wax off.


Great. So how is this going to work in real life?

1) Consistency / Advanced Scheduling
- Two week forward planning availability schedule. 
- Goal to arrange at least two sessions per week for OSCE practice / mentoring consistently.
- Schedule protected study time – with a target of 20 hours per week total.

2) Full Immersion
- Work full time. Live it. Breathe it.
- Slow the fuck down. Debrief. Ruminate. Reflect. Marinate in thoughts. Develop structure.
- I need to sit down for half an hour a day to ruminate and reflect.
- Regular debriefs/meetings with the senior consultants who have graciously offered to help.

3) Focus on themes and structure.
- Need to collate and compile feedback from various trials into themes.
- Develop structure to approach broad range of situations
--- What to do if a pt with XYZ is in front of you
--- How to deal with challenging communication/interpersonal scenarios
--- Describing procedures at an expert level
--- The oddly focused examinations (eg. neuro in spinal trauma) to be expert/slick at.

4) Avoid being in my comfort zone
- I have reached a stage in my career where I can confidently manage most things without too much mental effort. This is bad in a way. Why are we doing X? Is Z really the right option?
- I need to consciously focus on what can be done better.
- I need to actively seek feedback and critique or will never grow. As I have become more senior, this negative feedback is extremely hard to come by.
- ... to continue actual learning. Bit by bit. Every day.

5) Knowledge Refresher
- Spend about 30mins a day flipping through, and ruminating on trial written exam papers.
- (instead of reading textbooks, that does not help in developing heuristics / situational structure)



Sounds simple. Yet it’s going to need real focus. Here is where Ikigai comes in.
I enjoy what I do and look forward to going to work. The world needs emergency physicians. Im paid for it. Im good at it. And I freaking love it!

It shouldn’t be arduous. Annoying maybe (having to set up zoom meetings and lots of scheduling)… but enjoyable at the end of the day.