The Power of Serendipity and Multidisciplinary Learning in Medicine – Solving a Complex Clinical Case

Posted on May 19, 2016

In this talk, Dr. Sanil Rege provides an insightful glimpse into the world of both serendipity and multidisciplinary learning. He also explores their impact on value creation for psychiatry and patients.

Dr. Rege begins by discussing his journey with Psych Scene and explaining how serendipitous meetings with people led to the creation of new educational opportunities.

He then links these examples with a real-life case of a young girl diagnosed with conversion disorder / Functional Neurological Disorder. Multiple doctors saw the girl without a resolution of her fundamental problem, which was ‘seizure activity.’ The videos show the seizures occurring in sleep and wakeful states.

Verbatim communication between the Psychiatrist (Dr. Sanil Rege) and the Haematologist (Dr. Lachie Hayes) is displayed using the power of storytelling.

Through a combination of serendipity, careful history taking and the power of multidisciplinary learning, the culprit was identified. This resulted in a complete remission of the girl’s seizures.

The result was unexpected, and Dr. Rege’s talk provides several additional examples of how medicine has advanced through unexpected and sometimes serendipitous results.

This talk is conceptually linked to Professor Gordon Parker’s talk about heuristics and pattern analysis.

Key points:

1. Harness the Power of Multidisciplinary Learning:

Sir William Osler was correct when he said:

There are, in truth, no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs.

The clinical case required a detailed medical history and examination to solve it.

2. Avoid the Hammer and Nail syndrome:

Humans – and doctors are no exception – operate under certain heuristic rules. According to Kahnemann-

Heuristic is a simple procedure that helps find adequate, though often imperfect, answers to difficult questions.

It is for this reason Charlie Munger said –

The first rule is that you’ve got to have multiple models because if you just have one or two that you’re using, the nature of human psychology is such that you’ll torture reality so that it fits your models, or at least you’ll think it does… And the models have to come from multiple disciplines because all the wisdom of the world is not to be found in one little academic department.

Professor Gordon Parker similarly highlighted how pattern analysis, which is essentially an intuitive process, works most of the time but, in some cases, leads to errors.

Nobel Prize Winner and author Daniel Kahneman described two systems of thinking in his book, Thinking Fast and Slow:

  • System 1: the mental shotgun or lazy part, which looks for shortcuts – it is also the basis for intuition
  • System 2: the effortful and attentive system, which helps us in making judgements and choices

A combination of both systems is required to minimise errors.

The clinical case itself highlights how System 1 jumped to the intuitive diagnosis of conversion disorder, while the second, the more effortful part went through a process of ‘falsification,’ a term used by Karl Popper, or a process of elimination – much like Sherlock Holmes uses to solve problems.

Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth. – Doyle

3. Serendipity:

Most of what people were looking for, they did not find. Most of what they found they were not looking for. (Taleb, The Black Swan).

Most medical discoveries were accidents. Viagra was developed from blood pressure medications, penicillin was just another mould, the coronary arteriogram was a slip into the artery.

While many discoveries are written in a straightforward way, the truth is far from straightforward. Similarly, in clinical practice – and this may be a bitter pill to swallow – successful outcomes in medicine cannot be solely attributed to medical experts and specialists.

Returning to the case: many of you may wonder why the young girl was not diagnosed earlier – especially since she saw so many doctors –  and how the diagnosis could have possibly been missed.

The answer is luck.

Michael Mauboussin, the author of The Success Equation, said –

What if I told you that in many cases improving skill leads to results that rely more on luck? That’s right. Greater skill doesn’t decrease the dependence on luck, it increases it.

The question is not whether these experts are well trained. It is whether the world is predictable. – Kahnemann

Embrace uncertainty and serendipity might just find you.

Disclaimer: Written informed consent has been obtained to show this video and describe the case.

References:

  1. Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
  2. Karl Popper, Conjectures and Refutations, London: Routledge and Keagan Paul, 1963, pp. 33-39; from Theodore Schick, ed., Readings in the Philosophy of Science, Mountain View, CA: Mayfield Publishing Company, 2000, pp. 9-13.
  3. Mauboussin, Michael. The Success Equation: Untangling Skill and Luck in Business, Sports, and Investing. Boston: Harvard Business School Press, 2012.