Practicing Medicine by Ear

My grandmother was an aspiring mezzo-soprano opera singer in Italy before World War II. After the German Army was driven out of Naples, she met and later married an American GI, settling down in central Maine, where they started a family. Like many of the immigrants in the area, my grandparents worked in the local mills making everything from shoes to blankets. My grandmother never gave up singing and was renowned for stunning her coworkers with renditions of classic arias that rose above the rhythmic chatter of sewing machines and looms. I have rich memories from my childhood of Sundays with my Nonna. We would make fresh pasta and sauce together and her booming voice would saturate the kitchen with the melodies of her youth.

By comparison, my own musical career got off to a less impressive start. At times I “played” the piano, violin and even the recorder, all with little success. Then, quite by accident, I discovered vocal music. I had always liked theater, and when they needed singers for the school musical, I was cast in the show. From then on I was a singer, eventually landing a coveted spot in a summer supergroup of some of the best college a cappella singers in country. I accomplished all of this without formal vocal training or expertise in music theory. A childhood surrounded by musicians resulted in my learning to sing by ear. Without being able to read music, I could tell you what the next note would be because I knew which note “fit” the chord.

Looking back, my approach to clinical medicine in the emergency department, mirrored my early days in music: I practiced medicine by ear, trusting my clinical instincts, feeling my way through the interaction, rather than adhering to any formal analysis. And much like my musical career, my path to becoming a physician has been unconventional. My first exposure to medicine was in the pre-hospital arena as an emergency medical technician and firefighter. It was there that I developed my intuitive sense of sick and not sick. When I started medical school, I found that learning by the book was not as easy. Much like my music theory professors in college who were frustrated by my self-taught habits, my medical school teachers warned of the potential challenges posed by my past clinical experiences. At the time, I could not fathom that my previous experiences could be anything other than an asset. However, my instincts did sometimes lead me astray.

When I was an intern in the emergency department, I habitually received feedback from my senior residents and attendings that I needed to broaden my differential and consider other causes of my patients’ complaints. I was too focused on what my instinct told me was wrong with the patient to see the broader picture. Although frustrating for the intuitive diagnostician, this was a thought exercise, a way of training one’s brain to consider all of the possibilities before honing in on the diagnosis. The goal of such thinking is to avoid missing a diagnosis by clouding the picture with cognitive biases.

And yet, during the same shifts I would consistently see the same attendings who pushed me to think broadly leave a room and immediately know what the patient had. They did not present an elegant differential, they just knew that the ill-appearing, diaphoretic, anxious middle aged woman in room 3 was having an heart attack; before the EKG; before the labs; before the chest x-ray ruled out the other dangerous causes of chest pain we are all taught in medical school. They just knew, and they acted on this knowledge, calling it the “art of medicine.”

This paradox has not been lost on me as I have progressed through my career. As much as we are pushed to give due consideration to every possible explanation of a patient’s illness, we often are compelled to act on informed instinct as we face the overcrowded waiting rooms and throughput pressures in the emergency department. Our environment is detail deprived, time limited, and confounded by intoxication, mental illness, language barriers, socioeconomic disparities and an overworked system that funnels problem patients to us. A well-honed gestalt is useful. It is also at the root of many of our medical errors.

In the past the experienced attending physician would approach the patient, ask a question or make a cursory exam and then pronounce the diagnosis that had confounded the team of rounding residents. For many years, this Augenblick, or “blink of the eye,” diagnosis was the paradigm of medical decision making. As we have become more aware of the cognitive basis of error, the pendulum has swung away from such a paternal and celestial view of the physician.

Medical experts, metacognitive thinkers, even our Morbidity and Mortality process, all have pushed us towards understanding our inherent biases, and how these cloud our judgment. They speak of “the clinical gamble of trusting one’s intuition and note that “this automatic, unconscious mode leaves [us] vulnerable to make mistake[s]. The fear is that if we listen only to our automatic side, we will be subject to cognitive bias, anchor on a diagnosis and search until we accumulate sufficient evidence to support our intuition.

Neurobiologists and psychologists who study both the anatomy and the organization of cognition have created a framework to explain this inherent dichotomy in human reasoning. Put simply, we are hard-wired for two distinct types of thinking. System 1 thinking (or fast thinking) is non-analytical, intuitive, automatic and effortless. System 2 thinking (or slow thinking) is analytical, reflective, deliberate and effortful. In fast thinking, your brain sees the problem, searches your memory for the closest match, and then fits the problem in front of you into that memory. In slow thinking, your brain approaches the problem by methodically organizing your thoughts and planning a response. Applied in a clinical sense, these partitions could represent the extremes of clinical intuition and an exhaustively researched, expansive differential diagnosis.

What is an intuitive clinician to do?

Although these approaches seem to be polar opposites, emerging evidence from functional MRI studies shows anatomical overlap between system 1 and system 2 thinking. These differing approaches to thinking are far less conflicting than the theorists would lead us to believe, and exist more on a continuum. The brain constantly switches between fast and slow thinking to address problems. I for one, continue to value my fast thinking side. It is certainly adaptive in the emergency department where, much like the firefighter in a burning building, we are called to make decisions quickly and often with little information. However, as my own clinical intuition continues to evolve, I recognize that the key to avoiding diagnostic error is to know when to slow down a take an analytical look at the problem before you.

I have been wrong many times. I have confidently sung a note believing it fit into a chord, only to realize that the chord progression changed. I have been so blinded by my clinical instinct that I have missed an elusive diagnosis that would have been apparent if I had only slowed down and thought a little bit more about the patient in front of me. In the end, I still tend to practice medicine by ear. I still intellectually feel my way through the patient’s presentation. I listen to my instinct, but I have calibrated it with years of experience, thousands of patient encounters and a multitude of humbling moments. Ironically, it is now my instinct that tells me to slow down and take another look at the data in front of me, like taking a minute to glance at the sheet music and make sure I’m still in the right key. My Nonna would be proud.

 

Nick Asselin, DO (@EMDrNick) is an Emergency Medical Services Fellow at the University of Massachusetts Medical School. He practices Emergency Medicine by ear in Massachusetts and Rhode Island.

2 responses to “Practicing Medicine by Ear”

  1. Jason Bowman says:

    Great, thought-provoking piece Nick – thanks for taking the time to write and share this!

  2. Orlan says:

    Amazing, very good.