Commentary: Lowly interns, more is merrier, and the Casablanca Strategy

Test ordering is an integral part of clinical decision making. Variation in test-ordering behavior appears to reflect uncertainty in the clinical reasoning and decision-making process. Among decision makers, novices function mostly in the analytic mode of reasoning, experiencing high levels of uncertainty and, therefore, account for the most variance. While less discriminate test ordering has both economical and clinical downsides, it nevertheless remains a rite of passage along the road toward expertise. In response to the article by Iwashyna and colleagues, the author of this commentary reflects on the implications of test-ordering behavior in the academic medicine setting. The process of ordering tests can serve purposes other than the obvious, not the least of which allows the decision maker additional time for reflection in the decision-making process, perhaps leading to a less mindless and more mindful approach. The author observes that test-ordering behavior of novitiates might be optimized through a variety of strategies that improve both active and passive learning in the clinical environment. In addition to specific education around costs, as well as Bayesian considerations, active learning importantly requires exposure to those processes that may subvert clinical reasoning, notably cognitive biases. Passive learning is enhanced in supportive environments. Throughout, those who supervise and teach should provide effective models.