Dr. Jeremy Sharp (01:19)
600. 600 episodes. If you had told me that number at episode one, I don’t know that I would have believed you, to be honest. But here we are, and the fact that you are here pressing play on number 600 is the reason this show exists at all. So today’s a little bit different. This is not an interview and it’s not necessarily a deep dive into one specific business topic.
Today is what you might call a playbook. So, you know, six core principles that keep coming up, episode after episode, guest after guest, year after year.
This is the stuff that I think actually holds a practice together, a life together, a career together over the long run. So if you have been here since the early days, think of this as a reunion of sorts of material that you have heard already.
bringing back into the room. But if this is your very first episode, welcome. This one could be your start here. Let’s get to it.
Dr. Jeremy Sharp (02:36)
All right, everybody, we are back with episode number six hundred of the Testing Psychologist Podcast. So here’s the thing about number six hundred it’s not really about the number necessarily. I think it’s about what the number represents. Represents sustained, structured effort over a very long stretch of time. It’ll be nine years in January of twenty twenty seven.
And turns out that’s not a bad definition of how anyone actually gets good at anything. Not to say that I’m good necessarily at podcasting, but I have certainly stuck with it for a long time, and I think I’ve improved. So there’s a common myth that expertise is mostly talent or mostly just time served. The evidence, though, says otherwise. So there’s a 2022 paper in the New England Journal Medicine that looked at deliberate practice.
in clinical reasoning specifically. Deliberate practice. So this is a structured, feedback driven, reflective effort aimed explicitly at getting better. Not just repetition and not just showing up. What they found is that deliberate practice is a stronger predictor of clinical performance than academic aptitude or years on the job. So you might think, I mean this makes intuitive sense, right? But
I think it’s important to articulate this key component. It’s not just showing up. It’s not initial talent, so to speak, but it’s just deliberate practice, which is admittedly tough to find in our field. There aren’t very many very many people who can sit and look over our shoulders and tell us whether we’re doing something quote unquote correctly or incorrectly. So that distinction matters. doing the thing over and over isn’t the same as getting better at the thing.
I mean, we all know I think you could practice a mistake for 20 years, right? So the framework behind this was reformulated specifically for medical training by Anders Ericsson in academic medicine back in 2015. So you might recognize Ericsson, you know, from the 10,000 hours theory of expertise. But it was built around lifelong self-regulated learning. And I want to flag one thing while we’re here because it comes up every single time this topic does. The famous like 10,000 hours idea that I referenced just a second ago.
That number is always an average, never a clear-cut threshold. So it got flattened in the popular retelling, I suppose, and you know, popularization of this idea. We simplify things, right? That’s what we do. so it’s not like anybody crosses a 10,000-hour threshold and instantly becomes an expert. That’s not how it works. So, why am I talking about this here in the podcast in this first segment of my 600th episode?
Well, because a show like this and the reflective listening that you are doing right now is one of the modern ways that practitioners audit their own mental models. So you hear how someone else reasons through a case, you quietly or loudly or chaotically compare it to how you would have done it. And that comparison is the practice. Okay, so in a field.
And a subspecialty where we don’t get a lot of feedback. That is one thing that I’m I’ve really tried to do over the years is kind of blow open the doors on how other people, specifically experts, hopefully experts that I’ve identified, attack this job that we do. Which brings us to the two jobs of today’s episode. one, for the long timers, we’re gonna re-anchor you in the mechanics of doing this work well.
And two, for the newcomers, I’m gonna hopefully hand you a roadmap. to a whole catalog. Six principles. Okay. Six principles, one principle for every hundred episodes that I’ve done. Let’s start with one that everything else depends on. Okay, principle one. Fancy title right off the bat. Epistemic humility and updating your mental models. All right. What does that even mean? Expertise is defined less by what you know than by how willingly and how quickly you update what you know when the evidence changes.
Say that one more time. Expertise is defined less by what you know.
Than by how willingly and how quickly you update what you know when the evidence changes. Now, evidence changes a lot in our field, right? This is uncomfortable because most of us kind of build an identity around our knowledge. and this principle essentially says that the knowledge is the perishable part. the durable skill is the updating, right? So you can’t go through grad school or like read a few studies and you know, file them away and rely on that for.
Five, 10, 15, 20 years. The the skill here is actually updating your knowledge. The conceptual roots here actually go back to cognitive flexibility theory from the late 1980s. the idea is that in a complex, messy, like ill-structured domain, which is essentially like real practice with real people, like what we do, you can’t just retrieve a stored answer. You have to reconstruct your knowledge on the fly to fit a situation that you’ve never seen in exactly that shape before.
I’ll give you a quick note because these do get confused a lot. this cognitive flexibility is a theory about how we assemble knowledge for novel problems, right? That’s related to, but not the same as cognitive flexibility, like the executive function, which we many of us are familiar with, which is, you know, the brain’s ability to switch between tasks and rules. the current neuroscience on the executive functioning side is well mapped.
Including like which brain networks support flexibility and encouragingly the fact that it is trainable, which is good for us. But this is the part that is, I think, legitimately humbling. Changing your mind is not free. What does that mean? Well, a 2022 study by a few folks in biological psychology showed that integrating evidence that disconfirms what you already believe has a measurable neural signature.
So your brain works harder to accept I was wrong than to accept I was right. I think this makes sense. So when updating feels effortful, that’s not a weakness necessarily or a bad thing. It’s the actual cost of what I would say is one of the most important skills that we have.
So the takeaway here from this first section, this first principle is that once a quarter, I want you to name one core clinical belief or one routine that you run on autopilot. Okay. Just one. Just one. then you can go test it against the current literature, being honest with yourself, of course, and adjust the protocol if it doesn’t hold up quarterly. Okay. This is one of those things that you can put on your calendar because I think the beliefs that hurt us most are the ones that we stopped questioning.
Years ago. This also dovetails, I think, well, with some of the research in the book Range, which stated somewhat counterintuitively that people who’ve been doing a job longer, who are theoretically, you know, experts in the medical field, are actually worse at their jobs than earlier career folks. So there’s a good bit of research to support this. All right. Principle number two the primacy of alliance and communication.
So, this is one that people underestimate quite a bit, I think. When I say primacy of alliance and communication, we’re essentially talking about relationships. Okay. So the relationship is not like the soft, fluffy part around the real work that we do. In a lot of cases, the relationship is the mechanism. The anchor here is important, though. So there’s an article from the journal Psychotherapy in 2018, which is a meta-analysis of like 295 studies.
Cross therapy types, cultures, diagnoses, the working alliance is reliably and positively associated with outcome. 295 studies essentially pointing in the same direction. Okay, so that’s not a coincidence. But it gets a little more interesting. There’s a systematic review by several folks in clinical psychology in twenty twenty that asked a harder question, which is is the alliance actually a mechanism of change or just something that shows up when things are going well anyway?
And the majority of studies they examine, the alliance actually functioned as a mediator of symptom change. So, in other words, it’s not just a thermometer, it’s like actually part of the engine that’s driving the change. So, this fits what a guy named Bruce Wampold called the contextual model, which is the idea that intervention works through relationship, through positive expectancy, and through getting the person to take adaptive action. And this is not a face-to-face only phenomenon anymore.
So there’s some research in 2023 that showed that the alliance outcome link holds up through digital and blended care models as well, which is good for us because I think a lot of us are doing virtual intakes and feedbacks, even if we’re doing in person testing. So if the relationship carries that much weight, I think the failure modes matter. There are two big ones. first, jargon. Okay, so every technical term that you use that the person
Your client doesn’t share, puts a little more cognitive distance between the two of you. Second, locking on to diagnostic criteria before you’ve established any emotional safety is a pitfall. you can be completely correct and still lose the person. And when you lose the person, you lose adherence and trust. I think we’ve all probably had this experience in intakes or feedback sessions or during testing.
So what do we take away from this? there are essentially like two feedback loops that you can build into every session. One, transparent goal setting at the start or checking in with the client about what they are hoping to gather, what their goals are for the evaluation. So you can say it out loud, reiterate what they what they want. You know, this fits really well, you know, pulling a page from the therapeutic assessment model where you’re asking what kind of questions they have, but we should be doing that in some form or fashion.
Make sure that we are on the same page as the client from the very beginning. That’s the first thing. The second thing is an explicit check-in for shared understanding, like during testing and again at the end of testing. So you could say something like, here’s what I think we’re working on, here’s what I think we agreed on, here’s what I think is important to you. Did I get that right? It’s usually a pretty quick process, but it I think protects probably the most important and powerful variable that we’ve got because
When we get to that feedback session and make those recommendations and offer those diagnoses, we want to make sure that we have a really strong working alliance with the client or the parents or the kid or whomever we might be speaking with.
Dr. Jeremy Sharp (14:24)
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Dr. Jeremy Sharp (15:29)
Okay, principle number three, systemic hygiene over individual resilience. Again, what does this even mean, these fancy titles for these sections? I want to be careful, okay, because this is the one that might be most likely to get misquoted. All right. What do I mean by that? Well, we can start with a classic example. So Maslak and Ja Jackson, sorry, in 1981, gave us three dimensions of burnout that we still use.
Emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. that framework has held up for like four decades. What’s changed though is our understanding of where burnout comes from and what to do about it. There’s a study in the New England Journal of Medicine in 2024 that made the case that system level interventions, so the ones that target like work hours and workload, have moderate to large effects and should be prioritized.
That’s great. And then another kind of head-to-head meta-analysis by De Simone and colleagues in 2021 found that organization-directed interventions outperform interventions aimed at fixing the individual. So the headline here, I think, is that you can’t like gymnastics your way out of a broken system. Self-care doesn’t substitute for adequate administration time or administrative time, real workflow.
Boundaries and like a manageable caseload. So I did a full episode on burnout probably three to six months ago that you could go check out to get real deep in this topic. But this is the you know the takeaway for that content. This is where I wanna, you know, be pretty straightforward. The story is not like systems good, individuals bad, or individuals irrelevant. there’s another meta-analysis in 2025.
That found that professional coaching probably does reduce physician burnout, while individual mindfulness programs may not. That is super interesting to me. Coaching likely works, mindfulness might not. So it’s not like individual-level strategies are uniformly weak. some work and some don’t. there’s some other commentary from a couple other top-tier journals.
Kind of pushback on treating like organizational versus individual as a clean like either or because of course they operate together in reality. So I think the probably the clearest framing is this: like system level factors are probably the most dominant and most effective lever, and it individual support is complementary, not a substitute, not a distraction. So you got to do both together. So what does this mean for your practice? What does it take away? you could run a workflow friction audit.
You can find two administrative tasks that drain your energy without improving a single outcome for the people you serve. I know that they’re out there. I’ve done this so many times in my practice. Then you automate them, delegate them, or eliminate them. Two tasks. Okay? That’s a systems intervention you can actually do this week if you want.
Okay, principle number four, bridging the knowledge to action gap. This one’s a little more descriptive. So this is the gap between knowing and doing. And unfortunately, it’s wider than almost anyone wants to admit. So the framework here is knowledge to action, which came from Graham and his colleagues in 2006. It was summarized a little more recently here in 2021. So it splits translation into two parts, essentially creating the knowledge.
And then an action cycle to actually put it.
So you’ve heard the statistic probably that it takes an average of like 17 years for research to to reach routine practice. 17 years. that number’s real, but it does not come from any of that, like the knowledge to action paper. It traces back to a study from 2000 and got popularized through the Institute of
Medicine, I just want to set that record straight. I don’t know if I’ve actually quoted that statistic here on the show before, as as we know, it’s been six hundred episodes, but just making sure that we’re clear on that. But there’s a counterintuitive part. the bottleneck usually is not access to evidence. Okay. We’re drowning in evidence, actually. The bottleneck is the absence of a systematic process to translate that evidence into real work or like a workflow.
There was an overview in 2024 by a few folks that pulled together, I think, like 86 systematic reviews and found that no single strategy wins everywhere, but a multifaceted approach tends to do better than any one tactic alone. So, how do high performers filter what actually crosses their desk? There are three questions. One, was the methodology rigorous enough to trust the conclusions? Two,
Does a sample actually reflect the people I work with? And three, most people skip this. what exact change to my daily protocol does this finding warrant? And if the abs or if the answer is none, that’s fine, but you still have to ask it.
So what is the takeaway here? You can build a one-page decision tree or a checklist for your highest frequency clinical scenarios. So there are plain tools like audit and feedback or you know simple decision aids. These are among interventions with genuinely positive effect sizes. So turn this guideline into something you can actually run in real time.
All right, principle five, the power of microinterventions and incremental gains.
This is probably the opposite of what we’re trained to reach for, but I’ll talk about this quite a bit. we tend to overinvest in these grand, like complex plans, and we chronically underestimate the small, boring habit that is done consistently. So this lines up with some of the research that I’ve already mentioned, actually, which is that structured low-cost tools or changes applied reliably. Okay, so these are like checklists.
Decision trees, reminders, these carry like very positive effect sizes in behavior change research. Okay. So this stuff is not super attractive or flashy or anything. It’s just like simple and reliable. So the principle underneath it is that consistency beats complexity. a simple evidence-based intervention or you know, plan or workflow or whatever applied every single time will outperform like this elegant, intricate protocol you only manage to to do.
When you remember to do it. The intervention that you actually do beats the better one. You don’t. So this is like a perfect example of don’t let perfect be the enemy of good, right? And I’ve done this a million times. Like I get caught up in all these tech tools and like I’ve built apps that I used for a week and then never used again. You know, workflows, like report styles and shortcuts and stuff like that. that I just don’t use. It’s like the simple stuff. It’s the simple stuff.
That you can apply daily, like day in and day out. Text expander is a good example of that for me. It’s super easy to use. It’s not flashy, but I use it every single day. And it saved me like 50 plus hours over the past nine to ten years. So, what can you do? the takeaway here is to pick one micro habit, okay? Just one.
Maybe it’s like two minutes right after an appointment to write like a clear summary or you know, record those behavior observations or take down some diagnostic notes. the idea is that you can hold the habit for thirty days before you think about like making it more complex or adding anything else. You just master the small thing first. Okay. Compounding. Compounding behavior tends to do the rest.
All right, now for our last principle, which is community as a clinical engine. So this kind of ties the whole show together. Solo practice and highly specialized work have a a sometimes not so hidden cost, and that is isolation. When you’re on your own, peer consultation can dry up, cognitive fatigue accelerates, you lose the people who would have told you.
That you were missing something. Okay. Many of us lose those colleagues that we’re used to being around, either in grad school or in our agency jobs. And this connects like straight back to principle three: the burnout evidence. Okay. Professional coaching came out as the individual-level intervention with the most consistent benefit in that 2025 meta-analysis. And the work from 2021 showed that you know system plus peer approaches.
Definitely beat isolated efforts. Okay. So community is not like a nice to have thing. It is truly like the engine that can drive your practice. And it’s protective for you. it makes you better and I think it keeps you in the game longer. And that’s a big part of why this podcast and my membership community and the Facebook group and my in-person business retreat every summer, like that’s a
big part of why all those things even exist. I mean, this is essentially like a huge peer consultation group that just happens to, you know, have met six times a month for the past, you know, nine years, almost nine years.
So I’ll just say it again. thank you. Thank you. These 600 episodes exist because all of you kept showing up. you post questions in the Facebook group, you challenge one another, you make me think, you tell your colleagues to listen, you have liked and subscribed and written reviews. And that’s what I think turned it very quickly in the beginning from
Like a broadcast into the void into what I consider like an actual conversation. even though we are separated physically and temporally, I’ve always considered this like I’m talking to everyone out there. Like this is just a conversation that we get to have several times a month. My hope, you know, looking ahead to the next hundred episodes is to continue to do deeper dives into the literature, bring in these expert guests that just continue to show up.
I’m so impressed with, and continue to, you know, do these business episodes that are rooted in research and not just anecdote. So showing you, you know, the what, the how, how do we, you know, do this work the best that we can and build sustainable practices that that actually fit for our lives. So there were six principles here: epistemic humility, alliance.
Systemic hygiene, closing that knowledge to action gap, microinterventions, and community. So, like I said, this will probably sound familiar to those of you who’ve listened a lot. But if you’re new, that is like the playbook in one episode. Okay. So all you have to do is pick one of these things to work on this week, and you can come back to the others when you have time. But stick with one for now and see where it takes you. So here’s two 600 past episodes and
Hopefully six hundred more to come. I’ll see you next time.
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