How medical diagnosticians earn their stripes: Horses, zebras, and divergent thinking

The acquisition of medical expertise is a rigorous endeavor that involves developing a range of cognitive, technical, and interpersonal skills. While clinical knowledge is routinely tested through written and practical examinations in medical school, benchmarking expertise performance for experienced physicians has proven more challenging. The present article considers the acquisition of medical expertise from candidacy through residency and clinical years. Particular attention is given to the skills that distinguish routine Journeymen medical experts who settle for a lower level of automatic skill from adaptive Experts and Masters, as well as the difficulties in defining the metrics required to distinguish these levels. A model of the physician as both a knowledgeable and creative expert is proposed, drawing from multifactorial models of expertise together with the Four Cs model of creativity at each stage of acquisition. Particular emphasis is placed on divergent thinking, a form of creative problem-solving. The benefits of divergent thinking in medicine are discussed in relation to core cognitive functions supporting the acquisition and maintenance of medical skills, differential diagnosis, cognitive heuristics and biases, and the drive for both personal and social innovation. In particular, a novel argument is put forth for the role of divergent thinking and cognitive flexibility as facilitators of expertise acquisition in the medical field. Recommendations are discussed for the integration of divergent thinking training into the medical selection and training practices to support the development of medical expertise.