Clinical gist and what we measure

Interesting commentary:  Lloyd FJ, Reyna VF. Clinical Gist and Medical Education JAMA Vol 302 No 12, 1332-1333

The authors describe two types of memory: verbatim and gist.

As you'd expect, verbatim is about remembering specific things & lists of things, gist is about remembering the underlying concept.

It seems that these memory types are independent - strength in one does not predict strength or weakness in the other.

From studies of these two memory types they point out three implications:

1:  "...gist memories endure over time and are more robust to interference from distractions such as stress or interference."
2: Learning environments assess for verbatim learning "List the three things..."  "What are the top ten diagnoses..." but are not as good at assessing gist.  Good clinicians rely on gist and can for the most part look up facts on the internet.
The authors give an example of a medical trainee presented with a 4 year old child with fever, runny nose, sore throat & family members sick with the same thing.  A verbatim assessment leads the trainee to assess for sepsis with blood cultures, to use imaging to evaluate sinusitis, strep test, etc.  A gist assessment would lead a trainee to diagnose a viral upper respiratory infection and prescribe acetaminophen rest & observation.
3: Medical training is typically aimed at lists and facts that can be easily gleaned from on line medical resources, yet evaluations of medical facts (that deteriorate in memory over time) imply that older clinicians are at risk of providing substandard care.

"The upshot of this distinction between verbatim and gist memory failure is that verbatim memory failure can be remedied easily with cognitive assistance from online information tools and is fundamentally different from not understanding the clinical gist..."

What I find most fascinating in this commentary is the degree to which medical quality is assessed based on the verbatim model and how little we measure based on the gist.  In Milstein's Health Affairs piece we see that the critical elements leading to improved care and reduced costs is the gist of effective primary care, yet we find the laudable principles of Patient Centered Medical Home bastardized into a verbatim list that more accurately reflects Doctor Centric Technology Marvel.

We really need a national conversation about how we measure quality.  The Cartesian verbatim approach is missing the forest for the trees.

Comments

[jean]

hmm
Takes common snese talking to people stuff to arcane academic levels.
Which makes me wonder what on earth the world has come to
Jean