Sunday, April 19, 2009

boggle, fossil digs, and patient care

I recently started playing a "Boggle" knock off on my IPhone. It's a frustratingly addictive game. When you first look at the 16 different letters on the 4x4 board, I usually only see a few words. Then, at some point I start getting a feel for the board, and start seeing a bunch of words that are within a letter of each other (sit, site, tie, ties, ....). Before I know it, 2 minutes are up, and I've still only seen perhaps 35 out of 130 possible words.

Playing it on a computer makes me realize how poor I am. When you play with friends, if I get 35 words, I feel like you've accomplished something, because I didn't realize that there were 130 words available for play.

It reminds me about what has been said about Michelangelo (or it may have been Leanardo da Vinci)- that when he looked at a block of marble, he could see the statue he was going to make, and all he had to do was chip away the marble that wasn't part of the statue. The point is that patterns are out there, and the limitation is in the human mind's ability to process what is right in front of them.

I most directly confronted this limitation in human observation 12 years ago, when I was in graduate school on a fossil dig. It was much less fun than it sounds, in no small part because I may be the world's worst fossil digger. We were looking for very small mammal fossils, with each bone being smaller than my thumbnail.

I remember one hot day, when I staring at a patch of dirt for over an hour. The patch wasn't particularly big- perhaps 3 feet by 3 feet, and I didn't see anything besides dirt and pebbles. Eventually, the expidition leader came by, and within 1 minute of looking at the same dirt I has spent an hour looking at, she was able to pull out three fossils. Through her more experienced eye, she was able to see things that my mind wasn't able to see. It was a striking (and humbling) example of how it takes practice to see patterns amongst the chaos.

This phenomenon comes up frequently as a physician. When I was first learning how to read MRI images, at first the images looked like a lot of noise to me. As I gained more iterations through practice, I started to filter out the noise, so at this point when I look at an MRI, I see lots of signal and very little noise.

This pattern repeated itself as I learned different techniques, whether it be performing nerve studies (electromyography and nerve conduction studies), spine injections, or using musculoskeletal ultrasound. It just takes practice.

It's a very similar way of developing the skills of playing Boggle. When you play Boggle, you eventually learn that it the word SITE is on the board, that you may also be able to spell TIE, and if you can spell TIE, you can probably also spell TIES, and SET, and SIT, etc. You learn which words commonly go together. So instead of seeing one word, you see 6 words.

Similarly, when you are looking at fossils, you learn that fossils will have rougher contours than pebbles, so you start to filter out the smooth contours.

Same thing with reading MRIs. You learn what a normal spine should look like on an MRI, and start filtering through if there is anything that looks abnormal.

One of my favorite cliches is that you need to listen for the dog that doesn't bark. I've actually never read any Sherlock Holmes novels, but my understanding is that he cracked a case because during a robbery, no one reported hearing the dog bark when someone broke into the house. This absence of a noise that should have been there indicated that the dog probably new the thief. It's a great example of knowing what should be present, and therefore being suspicious when the bark is absent.

I bring all of these tangential topics- Boggle, Fossils, Barking, etc- up in the context of patient care. I had a very interesting day of clinic on Friday. My patients had the normal mix of presenting symptoms- low back pain, knee pain, shoulder pain- but in fact my patients had an unusual mix of underlying problems that were far from straightforward.

I had a very good resident with me. After he had seen the patients, I asked him what I always ask the residents- "what do you think is going on, and what do you want to do?" We had one straightforward patient, but for all of the others, he wasn't sure what to do.

A common medical cliche is that we can all see the common diagnoses, but while we unusual diagnoses may see us, we may not see them. For example, I see hundreds of patients with herniated disks every year, but some of the patients who seem like they may have herniated disks may actually have cancer. One of the reasons patients see a fellowship trained specialist is for our ability to sniff out those odd cases.

It was interesting to watch the expression on my resident, as I could tell that he knew something was different with these patients, but he had not yet developed the experience to work through the differential diagnosis and determine what was actually going on. After I worked through the examination and discussed things with the patient, it became obvious. I am guessing, thought, that the experience was similar to playing Boggle when a competitor sees a word that was right there under our noses, or my experience when my expidition pulled out a fossil right from where I had already been looking.

And I guess that is what experience is all about- developing enough iterations to become a better observer.

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