Early Career Habits of Master Clinicians: Can Publication Lead to Democratization? (Commentary)

Clinical mastery is a shared aspiration for many who enter medical training, but only a select few truly achieve it. Those who do seem to share basic approaches to attain recognized excellence in diagnostic acumen, communication and interpersonal skills, medical knowledge, professionalism, negotiating the health care system, and lifelong learning.^1–4 However, the majority of practicing physicians arguably function on a spectrum from competent to proficient (rather than expert) clinicians. Referencing the 5-stage model of expertise acquisition,⁵ the “competent performer” (stage 3) responds to feedback and an increased sense of responsibility as his or her situations outgrow the limited rules learned at the novice (stage 1) or advanced beginner (stage 2). When a learner is able to assimilate feedback and channel it into an effective response, he or she reaches proficiency (stage 4). The expert (stage 5) transcends the active decision-making that marks proficiency with an ability to arrive at immediate, intuitive responses to situations. These stages of expertise are the end result of formalized classroom instruction, clinical clerkships, supervised postgraduate training, and individual experiences in practice. It may not be surprising that this educational process creates physicians who achieve an acceptable “stable and autonomous” level of skill,⁶ or, as stated by a participant in Kotwal et al: “A lot of us get stuck at good.”⁴

For those who choose to pursue a higher level of clinical expertise early in their career, existing guidance may feel incomplete or the outcome beyond their reach. In this issue of the Journal of Graduate Medical Education, Murthy and colleagues⁷ describe their efforts to identify habits employed by current peer-identified master clinicians that originated during their first formative years in practice. Through a series of interviews, the authors used a qualitative approach to sample and organize themes around clinical mastery, which they then extrapolated into practical strategies for residents, fellows, and junior clinicians. Their findings overlap with previous articles on current strategies of master clinicians, which they rightly found reassuring. The list of action steps by Murthy et al adds to previous suggestions championed by Dhaliwal.⁸ Participants' potentially reduced ability to accurately reflect on their past practices without bias is balanced by the power of memorable patient vignettes and formative conversations with colleagues that solidified their approach to lifelong learning.

Murthy et al cited the model of purposeful practice⁹ as an aligning framework for these early career habits, and the key elements (focused practice, specific goals, and crucial importance of feedback) are clearly seen in the findings. However, their unique emphasis on early career experiences allows them to link the crucible of a busy first clinician-educator job with the final component of purposeful expertise development: getting out of one's “comfort zone.” Beyond individual efforts, the habits discussed also exist in a larger, complex health care environment, and thus the importance of peer relationships is also crucial. Bandura's social cognitive theory of self-regulation is a useful lens through which to view the reflections of these established master clinicians.⁹ In this model, individuals self-observe, self-diagnose, and self-motivate to judge their behaviors, and then initiate change in an environment where they are regularly observing and interacting with others.

By focusing on participants from an academic medical center, the authors prioritized mastery in diagnosis, communication, and teaching. As a result, the majority of the comments and themes pertaining to clinical practice focused on diagnostic reasoning, rather than patient management. Management reasoning, in contrast to diagnostic reasoning, is the process of making practical and logistical decisions about treatment options, patient preferences, follow-up planning, and use of finite resources.¹⁰ While there are occasional overlapping examples of diagnostic and management reasoning scattered within the themes of the article, the scale and complexity of management reasoning presumably dwarf diagnostic reasoning; thus, its absence as an examined component is notable.

Can this article from Murthy and colleagues ease the path for residents, fellows, and junior faculty interested in becoming master clinicians at an academic medical center? At the very least it makes a formerly tacit list of behaviors more explicit and trainee centered, which extends a bridge from the future to those just starting to form practice habits. Even so, it is possible that the number of master clinicians in the world will stay static for the following reasons: the work of developing mastery is onerous, self-assessment is challenging, the health care environment often serves as an obstacle, and the availability of role models can vary across institutions.

Should all of us, who routinely care for patients alongside trainees, strive for clinical mastery? The answer is unequivocally yes, as the alternative is automaticity and arrested development.⁶ Consider your clinical and management reasoning processes, communication skills, and teaching methods. Break these processes into explicit steps that are spoken and transparent for students, residents, and fellows. Find a sustainable system for tracking the patients you see. Model humility and express joy in your clinical interactions. Ask a respected colleague to observe you and provide feedback. Although successful master clinicians start their habits early, it is never too late for your professional identity to evolve while imparting these lessons on to the next generation of physicians. For those considering future scholarship in this area, a shift from similarly structured qualitative studies would be welcome. Areas of focus could spring from the questions posed by Eva and Regehr¹¹ in their exploration of the newly coined definition “self-directed assessment seeking,” or a larger-scale promotion of trainee metacognitive skills¹²—both of which overlap with the pursuit of clinical mastery. Innovative practices, instruments, or frameworks that reduce barriers to the action steps, outlined by Murthy et al in an effort to modify behavior, should also be rigorously investigated.^13,14 Above all, the participants in these studies demonstrate that the journey remains far more important than the destination, and provides benefit to patients and learners along the way, regardless of whether one eventually achieves a peer-awarded title of “master clinician.”