See, Hear, Feel

EP46: Dr. Philip Shapiro on metacognition

January 25, 2023 Professor Christine J Ko, MD Season 1 Episode 46
See, Hear, Feel
EP46: Dr. Philip Shapiro on metacognition
Show Notes Transcript

Join us for Part 2 of my conversation with Dr. Shapiro, where we focus more on metacognition - being aware of how you think and learn. Dr. Shapiro was mentored by Dr. Bernie Ackerman and shares some key practices he learned through that relationship. Dr. Philip E. Shapiro is a dermatopathologist and dermatologist in Meriden, Connecticut who founded Dermatopathology Laboratory of New England. He previously worked at Yale University and is affiliated with multiple hospitals in the area, including St. Francis Hospital and Yale New Haven Hospital. He received his medical degree from Albany Medical College and has been in practice for 34 years. He was formerly Director of Dermatopathology at Yale. He has numerous publications and has been a leading voice in dermatopathology throughout his career; his contributions include describing interstitial mycosis fungoides and pseudomelanocytic nests.

[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today i'm excited to continue my conversation with Dr. Phillip E Shapiro. In case you didn't hear the last episode here is his biography. Dr. Shapiro is a dermatopathologist and dermatologist in Meriden, Connecticut, who founded Dermatopathology Laboratory of New England. He previously worked at Yale University, and he's affiliated with multiple hospitals in the area, including St. Francis Hospital and Yale New Haven Hospital. He received his medical degree from Albany Medical College and has been in practice for 34 years. He was formerly Director of Dermatopathology at Yale, where I am now, and he has numerous publications and has been a leading voice in dermatopathology throughout his career. 

[00:00:43] I will move on to talking about metacognition: what metacognition means to you.

[00:00:49] Philip Shapiro: So I have to admit, I didn't even know what the word meant before I knew we were going to have this, so I looked that up, and one definition I came up with was awareness or analysis of one's own thinking or learning process. And then I realized I didn't know what the word meant, but I've been doing that for a very long time. When I went to medical school, I actually had the opportunity to play in the Albany Symphony Orchestra. I was a cellist and I loved music. My father was like, No, don't dilute your medical school with this. And I remember struggling after the first semester of medical school because I wasn't getting the absolute best grades in all the subjects. And I was always driven to be at the top. I remember the neuroscience professor came up to me at the end of one of the concerts, and I told him I was going to quit, and he talked me out of it. And actually, I'll tell you his name is Norman Strominger. And you know what? I just called him a few months ago to thank him for that. This is 40 years later. It was Norm Strominger, a very brilliant guy who told me that I didn't have to get the very best grades, there were more important things in life. 

[00:01:57] We all think differently. There's no one way to think or learn. I discovered, particularly when I was in medical school, that my attention span was not great. I remember I would have trouble sitting through a 45 or 50 minute lecture from a professor whose primary purpose was not to give lectures, but to do research. I found that I wasn't getting so much out of it, and I would do better if I went to the library and read the stuff, but that was just me. So that's when I really started thinking about how I learned, to really focus on this metacognition issue. So I started developing things like I learned to practice my cello after I ate dinner. Cause you had that postprandial sleepiness. And I couldn't study quite as effectively. I remember when I was a resident at Columbia, I knew that I would focus best in the morning. I was fresher. So I would get up an hour early every day and read Fitzpatrick, the standard textbook we were using back then. Even now thinking about how I practice, I've just been very conscious of how I work. People need to figure out what's best for them and then focus on that. 

[00:03:02] Christine Ko: I love what you said. Since you mentioned practice and how you think about how you can do things optimally, can you go ahead and talk about that now? 

[00:03:11] Philip Shapiro: Some of this I might have gotten from watching how Bernie Ackerman used to work because he was my mentor when I was a fellow. I'm freshest in the morning. I try to look at my complicated cases early in the morning when I'm fresh, before the phone starts ringing. Ones that I find really complicated, sometimes I'll put aside, and I'll put 'em off for the weekend. Throughout much of my life, I've often worked one day on the weekend or at least a half a day, and I'll come in when no one's bothering me, and if I wanna dig up literature, I'll really dig into those. So that's morning. Then I work on my recuts and deeper levels because sometimes those require extra thought. And then I read the new cases in the afternoon. I'm reasonably sharp, but not as sharp as I am in the morning. And if I get a difficult case, I almost always like to look at it again fresh the next morning. Here's one of my rules about Spitz's nevus. I almost never sign out a Spitz nevus on the first look. I look at it again the next day to make sure I feel the same way about it the next day. . 

[00:04:07] Christine Ko: I love that. In addition to just being careful about how you think and thinking about how you best think and, maybe saving time on the weekend to really do a deep dive into a particular case or reading literature on a certain subject, how do you, how have you, or how do you, get better, like, continuously improve? 

[00:04:31] Philip Shapiro: I like to think I'm continuously improving. I think there are multiple facets to that. And this is something that I read when I was in medical school once about things one ought to do to try to improve. It's a combination of experience, practice. The more you do, the more experience helps you get better. I think reading is important. A lot of people, I think at our stage, do more case-based reading. So if you find an interesting case or you see a case at a conference, go and read about that. I used to do that a lot when I was a resident. If I would go to the Atlantic Derm and there'd be 50 cases, I would go with the book afterwards when I got home to the library and I'd pull out the references and read about those cases because now I had a patient in mind, and the things that I would read about would stick better because I'd have a place to put them. Another aspect is just talking with colleagues. But I think experience, reading, going to meetings, and talking with colleagues are all important parts of trying to improve one's practice. Something else I learned from Bernie. If you want to learn something, write about it or teach about it. I still remember, I can hear Bernie's words in my brain. You had to write the paper, you learn about it. That's a great way to learn, when you're writing about these things. 

[00:05:46] Christine Ko: Oh, perfect answer. I love it. When you actually see a patient with something and then you go and you read, you have a place to put that information. It reminds me of something that Jerad Gardner says, where he has like almost like little drawers in his head. And he just files information in there. I think that it's always been true for me, that I will retain information better if there's a patient associated with it. A real person. I think the reason is because when our emotions are involved, cognitive psychologists say it does allow us to remember better and to utilize our minds and brains better. It's a more efficient way to learn. I appreciate what you said.

[00:06:26] Okay, so one thing that I'm still struggling with, and I think that you will be able to give insight into this, is: I am deceived by my eyes, by the slide in front of me, by the patient in front of me. Cognitive psychologists call it the illusion of attention or inattentional blindness. I know that there's always that potential that I'm missing stuff. How do you deal with this? Have you thought about this? 

[00:06:53] Philip Shapiro: I have thought about it and the way I deal with it is slowing down. Again, it was such a great opportunity training with Bernie because he was so smart, and he had such great knowledge, and he made so many contributions, and we saw so much stuff, cases that would come in from other places. But I remember one thing that had a huge effect on me. The way Bernie used to work, he had a pitcher and a catcher, and those of us who were his fellows were aware of this. The pitcher would put the slide on the scope, the catcher would remove the slide from the scope. And Bernie got very efficient. I think he got too efficient because I remember, I'll never forget this case where I was the catcher, and as he was dictating the case as a nevus, I read the cover letter that the submitting physician sent. And it mentioned something about all those mitotic figures. And I said, Hey, Bernie. There's a comment here about all those mitotic figures, and he went back and looked at all the mitotic figures, and it was actually a melanoma. And I can't even remember at this point whether it was a metastatic melanoma or it was a nevoid melanoma. But that taught me a huge lesson. Here's a guy who, his knowledge is tremendous, but was about to make a mistake because he didn't go slow enough. And, similar vein, I remember I spent time with Geoff Gottlieb, who was a terrific dermatopathologist, and I remember him telling me once that every nevus deserves a look at higher power. Now some things are more important than others. Like I just mentioned, nevoid melanoma. I'm aware of certain danger areas. I'll mention a few specifics. Combined Spitz's nevi, and some of these we now know are BAPomas, or whatever term you want to use for them. That's another area I've learned is fraught with danger, that people tend to make mistakes. So I will slow down there. One of my favorites is the lichen planus like keratosis. Every time I see an LPLK, either consciously or subconsciously, I'm aware of the fact that melanomas may get a lichenoid infiltrate and look just like a lichen planus like keratosis. So that's how I deal with it. I slow down and I'm aware of some of the more dangerous areas where you could be fooled. 

[00:08:55] Christine Ko: Yes. I love that. Okay, so I'm gonna bring something up. Metacognition. The definition you gave earlier is awesome. Daniel Kahneman and his book Thinking, Fast and Slow: when we think about the way we think, he says there's two main ways of thinking. We think fast, and we think slow. And he names it System 1 and System 2, System 1 being fast thinking, instinct, gut; and System 2 being slow thinking, analysis, like hard math, because that's usually slow thinking, although for an expert in math, they still may be able to do it with System 1. The more expert you are in something, the more things become System 1 for you. When you're early on in a field, just starting, more things are System 2. So when you say to slow down, I think in Dr. Kahneman's terms, you're saying to use System 2. But what Dr. Kahneman says, which I think is really true for dermpath, and I would love your opinion on it, is that slowing down is important, but that fast thinking, that expertise that we garner, as you said, through practice, through reading slides, through talking with others, through going to meetings, through learning more and hopefully getting better and having more and more experience: that System 1 and System 2 are both useful. And it's not really an either or, that System 2 is better. I agree that it's important to slow down and think about these pitfalls, for example, in particular. But do you sometimes have a gut feeling about a slide? 

[00:10:26] Philip Shapiro: Sure. I think part of the key is knowing when you need to go to number 2. It takes experience, but it also takes being aware of this phenomenon and thinking, Do I need to really break this down more? Those cases where you're talking about where, you have a gut feeling, but may it still is not all coming together in your head. Those are very difficult cases, and those are often where I will come back and look at it a second day, and give myself a lot of time, and every once in a while, the third time. It's okay to admit that you don't know. Don't force something. Get another opinion if you need to. This is not an ego thing. You're taking care of a patient. Once, early in my career, one of my colleagues said to me, you get too many second opinions. This was way back when I was at Yale. I was like a year or two into practice, and I'm thinking, I'd rather get too many than too few. This is not a macho game. You're a doctor taking care of a patient, and if you feel like you need something else to help you out, go ahead and take advantage of that. Don't let your ego get in the way. But yeah, those are difficult circumstances that you talk about where it's just very difficult. 

[00:11:32] Christine Ko: I really appreciate what you said, that we should be able to say, I should be able to say, I don't know. I think that for too long, I will admit this, I unknowingly, unthinkingly, bought into that you're supposed to be perfect as a doctor and you're supposed to know. And if you don't, that's shameful. I'm struggling with what I think is a very perfectionistic medical culture. But in a way I get it. I'm like, it has to be right. We don't want to make mistakes on patients, ever. If I'm a patient, I don't want any mistake made on me at all. And yet medicine is full of human beings taking care of other human beings. And so there's absolutely no chance for perfection in that. I don't know what to do about that. 

[00:12:21] Philip Shapiro: I'm not an expert on this, but I think you do know what to do about that. You're doing it right now. You're asking the questions. In terms of making mistakes, yeah, everyone's going to make mistakes. The key, I think, is to figure out why people make mistakes and what can you do to minimize that. We can't be perfect. I think unfortunately some people use that as an excuse a little bit for not being as good as they could be. Mistakes might come in a couple of different ways. Some mistakes may happen because people just haven't done their homework in terms of learning their specialty as well as they should. And to me, those mistakes are easily fixable. And that really has to do with motivation and attitude. How much do they care? Then you have someone like you who I know is a superb dermatopathologist, who might make a mistake. That's not because you haven't done your training, that's because of the things you're thinking about now, these illusions and not thinking about things. But I think the solution is to do what you're doing. Say, why do people make mistakes and what can I do about it? And recognize, when do I slow down? When do I not slow down? And, what mistakes are more important? I'm much more careful checking margins on a basal cell carcinoma near the eyelid that has poor circumscription and is very infiltrative than a superficial basal cell carcinoma that's on the back, where it's not as important. Again, I try to get it right, but I'm less likely to get deeper levels. But I think this whole podcast, what you're doing, I think, is the right way. You're trying to figure out, why do we think certain way and how can we minimize our mistakes? 

[00:13:45] Christine Ko: That's very helpful. You just verbalized that at least maybe we can start with being really upfront with these sort of "smaller" mistakes, learn how to talk about them with each other, in a gentle way. 

[00:13:56] Philip Shapiro: Christine, it was great chatting with you.

[00:13:57] Christine Ko: Yeah, really fun. Thank you. I really appreciate your time.