On episode 10, I discuss one of the best public radio shows of all time, Car Talk, and how it’s an awesome example of clinical reasoning. I also talk a little bit about how doctors learn to think like doctors. Dedicated to Tom Magliozzi, who recently died.
I’m an internal medicine resident who spends his VERY little free time making podcasts about great stories in medicine — and ideally, what it means to think like a doctor — so it should be no surprise that how we train doctors — medical education — is a particular passion of mine. And because I am a resident, I have a unique perspective on the whole matter. I live in a strange little in-between world between student and “real” doctor. Because I — and quite frankly all my fellow residents — we are all real doctors. We care for the sick, we comfort the dying. We run codes, we counsel our patients about weight loss and high blood pressure, some of us deliver babies and do surgeries (not me, mind you). But we’re also still learning. We’re apprentices, really — journeymen doctors. And — believe it or not — we still have class.
And if there’s one thing doctors are good at doing — well, you’d think it’s medicine, but I’d put going to class way up there. Here’s a sobering fact — let’s say you’re a teenager who wants to be a surgeon. By the time you graduate high school, you’re only halfway through your education. And a good portion of those 13 years is spent sitting in class. First is college, with gen chem, organic chem, physics, calculus, and whatever other courses are required these days. Then the first two years of medical school brings anatomy lab, physiology, immunology, pathology, pharmacology, microbiology, biochemistry, and, of course, memorizing the Kreb’s cycle for the fifth time (#spoiler alert — I still don’t know it, and I’m still bitter). Mind you, these classes are necessary (though I have major qualms with the way that we teach medical students — and I feel like I say that every episode, but that will have to wait for another podcast), but that knowledge is NOT the same as learning how to think like a doctor. Finally, after all that, we release the poor medical students into the hospital to try and learn what it means to be a doctor, which they do by rotating between different services in the hospital, trying their best to be helpful and not get in the way of their overworked residents, all the while studying for very hard tests that determine a good portion of their grade.
Think about the qualities that make a good doctor, maybe someone who took care of one of your family members, a beloved family pediatrician or GP. You’d probably say, humanism, sympathy, caring. Or confidence. Or maybe you were impressed by your doctor’s clinical reasoning abilities in making a difficult diagnosis. What you probably didn’t think was, “Wow, that doctor knew the Kreb cycle real well!” Which is really to say that the qualities that make excellent doctors are not things that we teach in class — or that we could teach in class, even if we tried.
These qualities — chief among them clinical reasoning and humanism — are taught by osmosis. We hope that medical students (and residents, for that matter) spend enough time around expert clinicians on the wards, watching how they interact with patients and work through difficult clinical problems that they’ll learn (and practice) those skills for themselves. Of course, it doesn’t always work like that. There’s work to be done, patients to see, paperwork to fill out, tests to study for.
And this is the part of the show where we get to Car Talk. I’m sure this is a shock to most of you, but I absolutely love NPR. I’ve been working on my NPR voice for a very long time. Can’t you tell how well I annunciated there? My dream job, if I were not a doctor, would be to be an NPR host. I spend hours a day listening to podcasts. And, of course, the whole making a medical podcast thing. You get the picture; I’m a little bit of a freak.
So one of my favorite shows from my childhood was Car Talk, hosted by Click and Clack, the Tappett Brothers, the elder of whom Tom Magliozzi died a few months ago. Just in case you’re not familiar with the format, Car Talk was a call-in show hosted by engineer and car-enthusiast brothers Tom and Ray, where normal folk could ask any questions they wanted about their vehicles — however tangentially related — and get the their opinion. You can still hear it in re-runs. And it was — and is — awesome.
What does this possibly have to do with thinking like a doctor? Well, Gupreet Dhaliwal, who is one of those expert clinicians and diagnosticians that I’ve never met but would jump at the opportunity to, wrote an awesome op-ed in JAMA called “The Mechanics of Reasoning” where he argues that what Click and Clack do on Car Talk is identical to the task of the master clinician, with the added advantage that their audience of hundreds of thousands gets to have fun listening along.
He writes (and I quote), “The cognitive task of the mechanic is virtually identical to that of the physician: both use history, examination, and tests to diagnose and repair a complicated machine in the context of a human relationship. Students who listen to Car Talk can appreciate the fundamentals of problem solving and reasoning that serve both the mechanic and the physician.”
And, you know, I think he’s right. Click and Clack have all those qualities that exemplify an excellent physician. They start every encounter by building rapport with their patients (or rather, callers). Before the chief complaint is even known, they already know their caller’s name, hometown, and their job. I certainly can’t say that of all doctors. They take an excellent history, focusing on building a differential diagnosis. They construct what we call “illness scripts” — the heuristic we use to help us ask the right questions. For example, I might ask a patient with new back pain if he’s had any loss of sensation in a saddle distribution, because an uncommon cause of back pain is cauda equina syndrome. Dr. Dhaliwal gives this example from the show:
A woman recently reported receiving a shock every time her husband kissed her inside the car. Acknowledging their newlywed status, Ray still asked, “Did you recently get new tires?” Answer: Yes. Explanation: some tires cause static electricity buildup.
They build summary statements, they way doctors synthesize information from a patient’s interview into a coherent thought. For someone coming in with shortness of breath, I might say, “An elderly man with a history of heart disease presents with progressive shortness of breath and orthopnea (which is essentially worsened breathing while lying down)” and automatically start to think, well, this sounds like heart failure, but it could also be a COPD exacerbation, or fibrotic lung disease. They do the same thing on Car Talk: Per Dr. Dhaliwal: “Sounds like your radio loses power every time you abruptly decelerate on country roads. That can only be one of three things.”
And they’re good at their jobs. Click and Clack have a segment called“Stump the Chumps”, where they call back old callers to see how good their advice was. And they were right 71% of the time, which Dr. Dhaliwal points out mirrors the aphorism that a history makes the diagnosis itself 75% of the time.
Finally, and I’d argue equally importantly, Click and Clack clearly love their jobs. Their enthusiasm is infectious (in the good way, not the bad syphilis kind of way). They laugh all the time. They’re excited to tackle new problems. They love talking to all the wonderful strangers who call into their shows.
That’s one of the most important lessons to impart on learners in medicine. Being a doctor is awesome, if you let it be. We get paid to help people in their direst times of need. We get to tackle and solve clinical problems on a daily basis. We get to meet people from all walks of life. In the middle of paperwork, stress, studying, heartbreak, exhaustion, dehydration it can be easy to forget all this, but Click and Clack remind us all why we signed up for this in the first place.
Should we work Car Talk into the clinical reasoning curriculum at medical schools? That might be a little extreme. There are plenty of great ideas on how to better teach clinical reasoning to medical students and residents. But I’d argue that the very least we can do is, when confronted with a challenging situation, take a deep breath, step back, and think, “What would Click and Clack do?” And with that, rest in peace Tom Magliozzi.You and your brother were an inspiration to me and tons of other radio listeners, and hopefully to some doctors and medical students too.
Well, that’s it for the podcast; thanks for listening. This is the 10th episode, which is something of a milestone. I couldn’t have done it without all the feedback and encouragement from my listeners, so thank you guys. I have three favors to ask you — one, tell your friends about the show, because the more the merrier. Two — rate us and write a review on iTunes; apparently the algorithm can get you featured. And finally, talk to me! I tweet @AdamRodmanMD, and I’m on facebook @BedsideRounds. You can listen to all of our episodes at our website www.bedside-rounds.org, or iTunes, Stitcher, or wherever you get your podcasts. Thanks guys!
This was mostly an opinion piece, so our only source for this one was “The Mechanics of Reasoning,” by Gupreet Dhaliwal, published in JAMA in 2011.