Friday, April 13, 2012

What is "the doctor look"?

Docs who are reading, imagine this scenario.  You're walking down a hospital hallway, and someone in a white coat, stethoscope around the neck, rounds a corner in front of you and begins walking toward you.

Question #1.  You don't personally know this person, but can you tell from 50 feet away whether she or he is a doctor?

I've started randomly asking some colleagues this question, and the answer is uniformly "yes."  Doctors have no problem distinguishing other doctors from the nurse practitioners, clinical pharmacists, and physician assistants who also roam the hospital in white coats.  Heck, my questionees even volunteered that they can still tell the difference even if the person wasn't wearing a white coat (for the record, I have no interest in rehashing the Great White Coat Debate at this time).

Question #2.  "How?"  I'd ask next.  "How can you tell that person is a doctor without reading their name badge?"

The response to this question was usually a shrug of the shoulders and, "You can just tell!"

In my two-year Faculty Development Fellowship, I learned how a physician's diagnostic reasoning process develops over time.  Most expert clinicians are pattern recognition experts.  These seasoned docs, without conscious effort, match the scenario in front of them to what they have seen before.  They recognize a diagnosis without deliberately walking through a problem representation and matching it to an illness script, the way a novice physician does.

Interestingly, experts often can't explain exactly how or why they arrived at a diagnosis.  Something happens to the edges of those details we each try so hard to master in our medical training; they blur into indistinct edges, into fuzzy caricatures of diagnoses that wait for ocular input to subconsciously call them into duty.

So, I posed the above questions to my resident team this week; we were in the elevator with a gentleman with a mop and janitor's bucket wearing a hospital housekeeper's uniform.  The residents all agreed that the answer to the first question was "yes" but were stumped with the second.

The man with the mop didn't hesitate.  "It's the attitude!" he exclaimed.  "You can always tell who the doctors are by their attitude."  Unlike clinical pattern recognition, the diagnosis of "doctor" apparently does not require a career to acquire.

Perhaps, like most expert clinicians' patterns, it will defy a straightforward explanation.  He or she is a doctor because it, well, he or she just is.  No one has to explain why an apple is an apple; apples can be red or green, sweet or tart, crisp or mealy, but we recognize without difficulty that they're all apples.

Here's hoping I'm at least somewhere on the red/sweet/crisp end of that scale.

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