I know you’re joking, but the real answer is “metis”, ie the trial-and-error experience you can’t get from books. For me, that involved things like:
- Knowing how to react when people tell you about how they’re bankrupt and they hate their life and they were sexually abused as a child and they want to die. Not that there’s a *great* way to react, but just not staring open-mouthed or saying something embarrassing.
- Learning actual risk-levels for things. Books will say things like “It’s dangerous to take two SSRIs at the same time” and “it’s dangerous to take MAOIs with clomipramine”, but it’s helpful to learn that the former is a silly theoretical risk that might bother 1 in 1000 people a little bit, and the second will very likely kill you.
- Getting a feel for mentally ill people. If you see enough depressed people, you start to recognize them even if they’re not outright telling you that they’re depressed. If you see enough severely depressed suicidal people, you start to recognize when somebody’s approaching that level.
- Learning how to take a history/interview, including such pitfalls as “do I really have to do the whole cognitive exam?” and “frick frick frick my patient started crying now what do I do?”
- Learning mistrust. My first year of psychiatry I was *so* willing to trust people, just because everyone I knew in real life was a basically trustworthy person and my priors for anyone I met being trustworthy were high. After working with lots of dysfunctional people and getting burned again and again, I no longer have that problem. It’s not that I mistrust people, per se, it’s more that I…have a broader view on what kinds of relationships to the truth people consider acceptable, and try to take that into account and meet them on their own terms.
- Learning which parts of the textbooks were subtly influenced by pharmaceutical companies/lawyers/morality police/SJWs/The Establishment and shouldn’t be taken 100% at face value.
- Figuring out how much deviation from the textbooks is to be expected, versus how much means your diagnosis is wrong/your medication isn’t working/your patient is lying/you are hopelessly confused in your entire paradigm.
- Related: knowing the best things to do when nothing makes sense and there are no good options.
(I’m still in training and can’t claim to have actually mastered any of these yet, but I’m working on them)