Medical Education and the Risk of Premature Closure

Today I was introduced to the concept of premature closure, the practice of latching on to a diagnosis too early before considering all the conditions that should be in the differential. Having just finished my first year of medical school, I’m not surprised to hear that this accidental practice exists, especially after reflecting upon the education I’ve received over the course of the last year. Immediately, I can identify two aspects of undergraduate medical education that contribute to its prevalence.

First, a message that I’ve heard repeated over and over again this year is the idea that medicine is about memorizing disease scripts and being able to recognize them when they present in clinic. At my institution, this is enforced by our examinations: most of our question stems involve a patient case, and to solve the question, the student must recognize the condition the patient is suffering from and accurately identify the biochemical disturbance or appropriate treatment from among the answer choices. While the idea of a discrete categorization system for disease is attractive to me as someone who has spent her life memorizing things, I have heard from mentors and experienced first hand the reality that our patients, more often than not, go off script. While keeping a mental inventory of disease scripts can provide a solid foundation for the diagnostic process, a truly great diagnostician is wildly observant, capable of integrating their exam findings and visual assessment of the patient to determine how applicable their collection of mental scripts might be. As I’m instructed to memorize the short list of symptoms associated with common conditions as a first- and second-year medical student, I fear that I’m forfeiting my powers of observation to expand my mental catalogue, making myself susceptible to the dangers of premature closure.

Second, after spending a year in medical education, my suspicions have been confirmed: those who decide to pursue an MD are, more often than not, very interested in being right. I think this leads us to approach medical education in one of two ways. Some, overwhelmed by the quantity of knowledge it would take to actually be right with any degree of frequency, opt to feign confidence. They select a diagnosis and defend it adamantly, making it hard for others to enter into a productive conversation about their judgement. The other group, however, still terrified of being wrong, takes solace in the beauty of the differential diagnosis as an opportunity to pick many answers in hopes that the right one might be among them. The latter group is set up to avoid the dangers of premature closure, but the competitive nature of medical education leads many to fall into the paradigm of false confidence at some point in their careers. As I’ve worked in small groups to develop differentials, I’ve watched my classmates roll their eyes, ready to move on to the next question because they “know” what the patient on the paper in front of them is suffering from. This relatively pervasive attitude leaves me concerned that our current batch of medical trainees is struggling to buy in to the importance of the differential as a valuable diagnostic tool instead of viewing it as a time-intensive academic exercise with little application to the real world. I fear that this perspective will leave students at increased risk of succumbing to premature closure when they enter medical practice, perhaps with catastrophic implications for their patients.