RP301 – Medical Metacognition: Thinking in Action

Session Readings


Course Goal: To allow post-clerkship medical students at USUHS to continue developing the habit of thought that is reflective practice.

Objectives: By the end of the 4 week elective, students will:

  1. Sequentially read 4 books from well-known authors selected to encourage students to examine ways to develop mindfulness and self-awareness in their evolving medical practices.
  2. Create 4 self-reflective works (art, essay, poem, multi-media) that address the salient themes of these books, their own experiences in medicine to date, and offer consideration of the implications of those themes for the care they have, do, and will deliver to their patients.
  3. Attend 4 small group discussion sessions – 1 for each book read – in which students will be able to benefit from the perspectives of others and practice the skill of thinking in action.
  4. Create a work of art or attend 3 artistic performances, exhibits, etc. and write an essay that considers how and why that artistic medium speaks to the student, what this implies about their worldview, and how that worldview impacts the way they interact with others in the healthcare arena.
  5. Coordinate and host a Thinking on Action session with a minimum of 3 healthcare colleagues.
  6. Attend a didactic session on small group facilitation and thereafter co-facilitate (with a faculty facilitator) small group sessions in the Human Context in Healthcare, Thinking on Action and/or other curricula as available.

Week 1

BeingMortal Being Mortal by Atul Gawande, MD

This book, exploring aging, death, and the medical profession’s handling, and sometimes mishandling of both, resonates with many in the healthcare field who have been challenged when trying to determine (1) the best way to care for others at the end of their lives and (2) the way they would want to be treated at the end of their own lives. Indeed, research demonstrates that the way most patients die and the way physicians want to die are quite divergent, as discussed in this Radiolab Podcast. After reading this book, students will write a reflective essay in which they: (1) examine their reactions to the idea of death and dying, including their experiences with both to date; (2) explore aspects of the book that they found particularly insightful and rewarding; and (3) consider how this reflection is likely to change their practice of medicine in the future.

Better Better by Atul Gawande, MD

Was Voltaire right when he wrote, “Le mieux est l’ennemi du bien”(“Best is the enemy of good”) ? Is “good enough” the enemy of better? This book offers students the opportunity to consider the process of root-cause analysis in the context of self-awareness and self-reflective practice. Students will identify a specific area on which they want to improve and describe how they view Dr. Awande’s view of “better” in the context of their own self-improvement.

Complications Complications by Atul Gawande

Dr. Gawande writes, “We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time, lives on the line…the gap between what we know and what we aim for persists. And this gap complicates everything we do.” After reading this book, students will write a reflective essay examining their reaction to (1) situations in which they made medical decisions of which they were uncertain and (2) situations that caused them to consider their own fallibility. Students will then discuss the impact both of these had on them personally, and how that has impacted the way they now communicate with and treat their patients.

Outliers Outliers by Malcolm Gladwell

How does the concept of 10,000 hours required for mastery apply to medical education and practice mastery? Students will explain this concept in the form of a self-reflective essay examining their own training experiences and discussing where on the educational continuum of mastery they currently stand.

Blink Blink by Malcolm Gladwell

Students will describe rapid cognition as it relates to clinical accuracy. Students will place blinking in the context of clinical decision making and provide first person narrative examples of one positive and one negative blink they have experienced in clinical practice.

kalanithi When Breath Becomes Air by Paul Kalanithi

“When Breath Becomes Air” is Dr. Kalanithi’s eloquent gift to all who have chosen to “protect life – and not merely life, but another’s identity – another’s soul.” In this small book there are many avenues of thought to pursue. Among these are the idea that while there is both a cost to caring and great rewards. How can we as caregivers simultaneously remain compassionate and protect our hearts from the pain and suffering we see each day? This question will guide our class discussion.

After reading this book, students will write a letter to Dr. Kalanithi or create a piece of artistic expression that expresses what he has taught them and how they think it will impact their future practice.

 Week 2

Spirit Catches The Spirit Catches You and You Fall Down by Anne Fadiman

William Osler, in a lecture to Yale students on April 20, 1913 said, “It is more important to know what patient has the disease than what disease the patient has.” Students will discuss how the events of this book might have unfolded if Osler’s dictum were universally followed in the medical profession and will consider how following this dictum in their own practice may affect their relations with patients in the future.[i]


[1] Development of this prompt stimulated by prompt from author’s website: http://media.us.macmillan.com/rggguides/9780374533403RGG.pdf

The Storytelling Animal The Storytelling Animal by Jonathan Gottschall

Gotschall states that “we are hard-wired for story.”  With this in mind, what is the role of evidence-based and anecdotal-based medicine in (1) the medical decisions we make and (2) the way we outline a plan of care for our patients?  How does this impact our approach to encouraging behavioral change?  What is the impact of a patient’s ability to tell a story on our interest in them as individuals and our ability to provide quality care?  After reading this book, students will write a self-reflective essay that considers the impact of “story” on the way they listen to and hear their patients, communicate with patients and colleagues, make diagnoses, and develop and communicate treatment plans.  Students will also consider how they have or have not incorporated “story” into their loves outside of medical school and how this has impacted them in their role as developing physicians.

Kitchen Table Wisdom Kitchen Table Wisdom by Rachel Naomi Remen, MD

Finding who we are can often be challenging in the midst of medical school.  This is made no less challenging by the transient nature of medical student life at USUHS.  Dr. Remen discussed the concept of “wholeness” throughout the book.  In this self-reflective essay, students will describe a sentinel event in their medical education, how they reacted in that situation, what aspects of themselves they felt they left behind or had to “edit” before, during or after the event, why they did this, and how they might approach a similar situation in the future.

tweedy Black Man in a White Coat by Damon Tweedy

In his book, Black Man in a White Coat, Dr. Tweedy explores the impact of both systemic and personal racism on health and healthcare.  What is unique about this book is the way in which Dr. Tweedy explores his own racism, welcoming and encouraging us to explore our own racial biases.  There is no denying that race impacts health. Time and again, studies demonstrate that people of color have higher rates of hypertension, diabetes, hyperlipidemia, CVA, and death and that these rates cannot be accounted for on a genetic basis. In addition, while it may be comforting to identify the systemic racism in healthcare, systemic racism stems from personal racism. Consequently, any effort to address this challenge must start with a look within.

After reading this book, students will explore their own racial biases, how they have impacted the care they have delivered in the past, and how they think it might impact the care they deliver in the future.

 Week 3

How Doctors Think How Doctors Think by Jerome Groopman

Students will consider how the doctor-patient interaction influences both a physician’s ability to make a diagnosis and the diagnoses physicians make. Students will reflect on their own experiences in which their interactions had such an impact and consider the implications of this for their future practice.

What Doctors Feel What Doctors Feel by Danielle Ofri

Students will consider the conceptual divide between reason and emotion that has long existed in western thought. Students will identify examples, both from their own experiences and in the book in which reason and emotion intersect, discuss their perspective on these situations, and examine the implications of this for their own practice in the future.

Blunder Blunder by Zachary Shore

Students will identify cognitive processing issues that lead good people to make bad decisions.  Students will reflect on personal experiences with blunders in their own lives. Students will provide first-person narratives describing such events and implications/outcomes.  Students will describe how blunders and medical errors are related and develop a personal preventive strategy to mitigate ‘blunder risks.’

Week 4

Thinking Fast and Slow Thinking Fast and Slow by Daniel Kahneman

Students will recognize different cognitive processing schemes inherent in all human interactions. Students will reflect on how these systems apply to their individual experiences and potentially shape interactions with patients.

A Whole New Mind A Whole New Mind by Daniel Pink

In this self-reflective essay, students will discuss learning activities traditionally defined as residing in the “left brain” or “right brain” and consider patient care activities in which they have participated that highlight traditional differences in left/right thinking and contextual implications for patient healthcare outcomes.

You Are Not So Smart You’re Not So Smart by David McRaney

Students will identify common cognitive traps as they apply to “thinking shortcuts.”  Students will provide examples of 3-5 cognitive traps in which they have been snared during their own clinical experience and how this related to patient care.

Session originally created by: Cole Denkensohn | Santa Barbara Street Medicine | MITE Team Lead | Data monitoring, information technology, and evaluation.