Medicine, fast and slow

Thinking, Fast and Slow is a well-known masterpiece of psychology by the formidable Daniel Kahneman. He diligently illuminates two different pathways of thought, which he arbitrarily titles System 1 and System 2. System 1 describes our quick thinking, our snap judgments, our gut feelings. System 2 encapsulates our deeper thoughts, the way we systematically review information, the analysis that requires time and mental effort. The work thoroughly lays out many case studies of when System 1 or System 2 is more effective, as well as how we frame bias in our remembrance of experiences.

System 1 utilizes many quick decision-making heuristics. The “availability heuristic” and the “recognition heuristic” are two I often find myself using in medicine. The availability heuristic explains the phenomenon between the ease with which we can recall pieces of information and our beliefs about their commonality. For example, people tend to think tornadoes or plane crashes are more common than they truly are, because they are easily available in our mind due to their emotional and dramatic nature. The recognition heuristic explains the fact that when we are presented with two pieces of information, we will select the one we have more familiarity with as the right answer, even if it is not correct. This is part of the reason why drug marketing can be so problematic.

Daniel Kahneman beautifully details the ways in which we use these shortcuts of System 1 and fail to arrive at true solutions. The solution to overcome these failures is to put the effort in and switch to System 2. System 2 allows us to review relevant information and arrive at the correct solution when it requires more methodical thinking. It requires mental stamina and motivation. When experts, such as established attending physicians, have put in years using System 2, their System 1 becomes smarter and more reliable than the System 1 of a newly minted third-year medical student.

Medicine is an elegant balance between System 1 and System 2. Efficiency is crucial, as time is always lacking, and important decisions need to be made, both to save lives and to improve quality of life. However, details matter. Missing one tiny word or physical exam finding can lead to devastating consequences. When I see a patient, I have to sit down and systematically go through each problem on their list to make sure I address every aspect of these beautifully complex people. I often find myself feeling self-conscious when I present patients because it takes me a while to get through everything. Even when I need to make a quick decision, like when a resident asks me for an answer off the bat, I have trouble trusting my gut and believing in my quick reaction without the time to further review. I do not feel settled until I have worked through every last detail, and while I get anxious that others find me slow, I know this thorough practice is how I need to continue to work to live up to my own definition of quality care. My System 1 will improve as I continue to grow and learn, but for now, I will continue to use my System 2 to provide the best health care that I can at my early stage. I am working on believing in myself, especially when I have spent time and thought on a particular topic or patient, to trust that my instincts can be right.

The other concept from Kahneman’s work that I found particularly insightful is the idea of the “experiencing self” and the “remembering self.” The experiencing self is the way we actually experience an event, the emotions and reactions we have at that moment. The remembering self is how we feel when we look back upon the event. Humans have evolved to often categorize an event as good or bad depending on how we feel when we reflect back on it, and the end of the event typically has a disproportionate impact on our memory. The saying “all’s well that ends well” encapsulates this thought- as long as the ending of an event is positive, we will remember the whole event as positive. If an event ends negatively, we will have a negative connotation of the entire situation.

I am trying to keep this concept in mind as I go through my clinical time. The course of a day can change quickly, between the radiant joy after a positive patient encounter to the nagging insecurity when I answer a question incorrectly. I want to let myself try to experience every moment fully and remember the days as they happened at the moment. I want to give every instant its full attention as I rotate between many different residents, different attendings, different hospitals, and different specialties. It would be easy to remember each rotation by the final days, but as I have found in medicine, the easy path is often not the best choice. I will try to honor each patient and the incredible mark they have left upon me by always looking deeper for every detail and to trust my judgment when I have put in the work.

Claire Brown is a medical student. 

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