Experiential Learning Versus Thinking Outside the Box

A typical phone call with my mom involves learning about some of our family friends back home. Invariably, a given set of family friends would have someone my age who I either went to high school with or happened to socialize with in community events. I enjoy these updates because its great to see everyone carving out interesting lives for themselves.

In any case, I recently heard from her about a friend of mine who is now doing an internal medicine residency in Cleveland, OH. This chap was a year ahead of me in high school and someone I really looked up to as I tried to temper and use for good my pre-college pre-med craziness. Like everyone else, I ended up googling him thereafter and came across this really interesting article about a medical school experience of his in the New York Times.

As a physician in training, I am working on developing two skill sets. The first is building enough experiential knowledge in order to recognize important aspects of clinical situations more quickly and thereby reach a diagnostic and treatment pathway earlier on in the clinical encounter. The second is to "think outside the box" and develop a "broad differential diagnosis", meaning one thinks of all of the possibilities why someone might be coming into the hospital to start with and then using the available data to parse out what is more likely to be happening than what is not. Experience is important here, too. As you see more patients, you'll see some weird things, and those will get added to your possibility space as you move forward.

However, I've always wondered whether there are situations where these two skills aren't complementary. The first skill brings forth a form of pattern recognition: "this looks like acute heart failure because I've seen hundreds of these and that was it has to be." This is what experienced clinicians bring to the table. On the other hand, "thinking outside the box" involves convincing yourself that there is a non-zero probability that a rare diagnosis may be driving the picture. This is what medical students are good at, in part because they aren't really taught much about population prevalence and probabilities, evening the playing field between the common and the rare. But I wonder, at least at some points in time, if part of this is also because medical students are not "encumbered" by experiential knowledge. As a result, they can "go outside of the box" because they don't have tunnel vision? They come into a clinical situation with fresh eyes, in some sense like an outside consultant.

The NYT piece about my family friend discusses a situation where more experienced clinicians zeroed in on one particular diagnosis but then were at a loss when they didn't find the evidence to support this. My friend, a fresh wide-eyed third year medical student, was able to think outside the box about a rare illness that could unify all the laboratory results and physical exam findings. He turned out to be right. The piece goes on to discuss the value of a fresh, unadulterated pair of eyes.

I'm barely two months in to my residency, but I've been wondering how to optimize returns to my experiences while at least keeping one eye outside the box. On the other hand, I think, in general, the returns to experience are positive with almost all patients. That is, having more clinical experiences under your belt is usually better. In the other cases, which may be rare, maybe my best bet then is to rely on the fresh supply of medical students and doctors-in-training. Or maybe it actually does make sense for a hospital to have some weirdo like House, MD to outsource bizarre, intractable cases to. We'll each have our comparative advantage and can capitalize on "returns to specialization." Thoughts?