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?

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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

Strengths

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.

Weakness

Near zero empathy and low emotional intelligence.

Writtens in March 2021 – need to refresh knowledge.

Opportunities

There is time to organize and structure approach. 

Time to attend more courses.

Need to pass by 2026. There is time.

Threats

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

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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.

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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.

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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)

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Ikigai

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.

Ezradamus: Australian Inflation Will Be 20% for 2020-2023.

From January 2020 to January 2022

- M1 money supply rose from 1091 billion to 1639 billion

- M3 supply rose from 2164 B to 2663 B. (23% rise)

There is nothing wrong with expanding the money supply in times of growth. But when money supply goes up, without a corresponding rise in productivity, then the value of money goes down - this is textbook inflation.

All the random fluff and excuses you will hear about war / supply shortages / covid / demand pull inflation / "transitory" / etc have short term effects on the inflation rate - but the bottom line still stands - The money supply expanded by 23% in 2 years over the course of the pandemic. And im pretty sure the country didnt become 23% more productive (making goods and mining resources) over that period.

Macro > Micro every. single. time.

Hence, expect the increased money supply to dilute every dollar in existence. It is a tax against money. And dont let any politician tell you otherwise.

How does this effect me?

I have a rather old school way of looking at society. Broadly speaking, there are three types of people:

- Plebs: Work for others in an unskilled job that can be easily replaced by random Joe Blogs.

- Proletariat: Has a skill, but works for other at the end of the day. You have a boss above you. (this is me btw)

- Bourgeoisie: Owns means of production. The shoplots. Factories. Mines. People work for you. You own capital.

Plebs

Expect bills to rise faster than wages. Through every period of inflation with fiat currency, wages do rise, but not as quickly as inflation - it never does. Rent goes up because house prices go up.

Proletariat

Those luxuries you used to enjoy suddenly cost alot more. Starting to have to penny pinch a bit to meet grocery targets. But you take reprieve in the fact that your house has gone up 20% in value....ignorant of the fact that you need a place to stay and wont be selling it anyway. The house you live in is not an income generating asset. It doesnt mean anything...but at least you are buffered against inflation.

Bourgeoisie

Your stocks, shares and property values have risen sharply. Your workers are demanding higher pay - sure. Here's a 3.5% pay rise to calm the peasants and to silence r/antiwork.

Why all the fuss about interest rates?

If you are wondering why the money supply is increasing, the oversimplified explanation is that low interest rates makes money cheap to borrow. BANKS SPAWN MONEY INTO EXISTANCE WHEN PEOPLE TAKE LOANS*.  Traditionally, when money was limited by gold in the bank, low interest rates would be a massive help to lower income people. But now, the reverse is true. Because the supply of money is infinite. Low interest rates actually hurt the poor without them realizing it. It makes their pay more worthless as the value of money declines. 

On Helicopter Money

The really big problem with democracy is that it ends up being a popularity contest - and if the population is not educated about money, it is easy to bribe them with 'helicopter money' (payouts). What people dont realize is that whatever temporary benefit from handouts/tax breaks they may have will be offset by a tax on money (inflation). So what if you get $1000 if in the long run, every dollar you earn will be more worthless.

Im quite a fan of democracy. So im writing this blog post to make people more informed about money to promote accountability and good governance. Education is key.

Ezradamus

Of course, I dont have a crystal ball. But my educated guess is that by the end of 2023, most people will notice a 20% rise in their expenditure (groceries, utilities, etc) compared to Jan 2020. Time will prove me right or wrong. It sounds insane, but that's averaged over 4 years (1/2020 - 12/2023)... or about 5% per year. This is how insidious inflation can be. You dont think 5% PA is much, but it is actually insane in the grand scheme of things.

*with some limitations of course. There is a reserve requirement, legislated lending criteria etc... But at the end of the day it is really almost unlimited as interest rates approach 0% (it's 0.25% right now). In the US there's a fractional reserve requirement, in Australia, there are similar criteria set by APRA ("risk weighted credit exposures" etc.)

Project Magnum Opus

PRELUDE
    I am writing this to become a better doctor. To be able to function at the level of a consultant. There is no fixed syllabus. There are only outlines of topics that a consultant kinda needs to know about. It seems like an impossible task, but medicine is ultimately based on real life, and it cannot deviate from that. Medicine changes, but human beings do not evolve that quickly. I have 10 years of experience behind me, along with studying for the exams, which are based on real life, and will stay true to reality.

    This project is an integration of all previous study documents for consultant level exams, namely my collection of clinical decision making tools and copypastable templates, ECG archives, ABG archives, and collections of structured assessments and multiple choice questions.

    This aims to be the final set of notes in my career. It will be updated as appropriate and once complete I will look into versioning and QI.

APPROACH
    The topics are wide, and the knowledge required could be extremely focused at times. Remembering lists is meaningless. Everything has to be in working memory, well understood and structured to allow for rapid access on the floor. Quick. Intuitive. Practical. To achieve the required amount of practical working knowledge, basic principles are to be employed. The structure is similar to that of the International Baccalaureate diploma, in that each theme is broken up into chunks with a progression of concepts and logical themes.

    The separation of themes differ from traditional textbooks and references as they are oriented around clinical relevance and application. Compartmentalizing information in clinically relevant areas of working memory is a key goal of this project.

    As this project focuses on real life, many topics are deliberately superficial and to the point. There are also some topics that end up being oddly specific and detailed as they are relevant to clinical practice.

• Chunking. Breaking up each topic in to bite sized pieces that could be integrated into working memory. Each topic should be reviewable in about 1 hour.
• Minimising cognitive load.
• Pictures / diagrams / illustrations / questions*
• Each topic has to flow in a logical progression of thinking – from fundamental concepts to complex themes.
• Each topic starts with a question or clinical scenario – because that’s how real life works.
• Cutting out the noise: Information relevant to practical real life clinical decision making is to be included.
• Portability – if a presentation needs to be done on one of the themes, easily copy-pastable into a powerpoint.

VERSIONING / PROOF READING

    I hope to enlist some colleagues to help proof read the topics prior to publishing. Versions are identified by a date appended to each file.

PERMALINK
https://www.ezralimm.com/p/pmo.html