Mental muscle memory is one the most important things to cultivate when you are learning clinical medicine. It is the process of training yourself to respond in certain ways to certain stimuli. Even if you are facing a completely novel situation, mental training will allow you to carry out the essential tasks in the evaluation without wasting mental energy, that way you can devote all your attention to the novel signs, symptoms, and hazards that you are encountering.
Fire and EMS often do this much better than we do in the hospital. It is rare that a medical student or intern is taught “here are the five things you need to do every time you are in a clinical encounter”, or “when placing a femoral line these are the seven steps you need to carry out to do this safely”. Often in medicine, we tell novices to “watch this a few times”, and then “give it a shot”. If the mentor is good, they will talk about all the steps they are taking to carry out the procedure or encounter, and make certain that the novice understands all the steps. The next step is often not taken, and that is then asking the novice to “talk through” the entire procedure by themselves before they move onto another task. This last step is essential to creating muscle memory, and essential to learning, and it is often not done.
It is puzzling that these educational exercises are not an intrinsic part of the educational process for physicians, and I think if we are going to move to a safer medical culture, they will need to be. In many ways, physicians often have an irrational resistance to any attempt to “cookbook” medical care. I think for many physicians that trained in the 70’s and 80’s they may be a lost cause at this point, since these attitudes are pretty ingrained. But we need to make certain we do not allow these attitudes to gain a foothold in younger physicians.
Here are some muscle memory exercises, and I will put a bunch together for a Kindle offering soon;
1. Step by step account of how to move from recognition of respiratory arrest, to placement of a secure airway. This is probably a 20 step evolution and will often take place under high pressure, therefore it is vitally important to embed these steps.
2. Step by step account of resuscitating a patient with severe medical hypotension. What orders? What labs? Fluids? Antibiotics? Cultures? Etc.
3. Step by step evolution of placing a thoracostomy tube, or a central line

I am not going to write out these steps right now, because people will transfer their disagreement to the steps that I write out, while what I want is for people to realize that the broad concept of consistent clinical thinking is the key, not the individual steps.
JY

Everyone interested in learning how we learn, should read Daniel Kahneman’s recent book “Thinking Fast and Slow”. I have read a great deal of his work before, and I find it amazing to read something that actually explains the way that your brain works. It makes some sense that you can improve the way you make decisions by understand the way you decide.
The book and the generally accepted concept is that we think in two ways, System 1:intuitive (fast) and System 2: slow and deliberate. Much fast thinking occurs without our awareness of the process. This includes deciding someone in the lane next to you on the highway is about to do something stupid, realizing someone on the phone with you is angry, etc. Slow thinking is the reasoning and weighing of options that we traditionally associate with decision making. In medicine, problems occur when people learn to make bad decisions intuitively, leading to cascades of errors that often leave the person cleaning up with few options.
This is why it is so important to do the following with novice care providers:
1. Make sure you and they agree on the importance of a few basic principles. While it is possible to drill this into someone’s head, even if they don’t accept the reasoning, that is sub-optimal, and that knowledge will probably break down under pressure. Think of anything you have “learned” but that you never really understood (string theory, financial accounting, differential equations, the loop of Henle) and you know that you might be able to figure out the right answer to a question about one of those subjects, but your knowledge is shallow and can get confused very easily. If students don’t understand why airway should come first, it can be dangerous, especially if bad decision processes get ingrained.
2. Practice, practice, practice – you need to bring that intuitive decision making up in the light of day and look at it. The only way is to make people to think fast, and the only way to do that is to put them in situations or simulations that make them think under pressure. We all know it is rare for someone to function effectively in their first high pressure situation, but unfortunately that first high pressure situation may occur with someone’s health and recovery at stake. So its imperative when training to try to determine if your students really “get” it. If they don’t get it, try to figure out why, go through it again, and then look them in the eyes and say “got it now?” and then test them on it one more time. In essence this is what we do on rounds every day, first people do things because we tell them to, then they grudgingly realize that what we say to do makes sense, and then they understand it and teach those things to the next group.
This is also another reason why unneeded variability is so counter-productive. If you do things different ways for no valid reason, people will get confused and think that the process is essentially random. If they get that in their head, it can be difficult to break. We can’t standardize everything, but we should standardize the first 10-15 steps in any algorithm. That way things can get going along a solid path.