Healthcare Practitioners Thinking, Fast and Slow

By Bonnie Hutchinson

Tuesday, March 26, 2019, Saskatoon SK, about 7:30 a.m.:  Evan Pyra leaves his basement suite and goes out to his car to get a phone charger. He smells fire and sees smoke billowing from the main floor of the house. To his shock, the house is on fire.

He goes around to the front of the house and sees his main floor neighbour inside. She’s panicked and “sort of frozen.” She’s talking about going back in to get some of her belongings.

Pyra, a 26-year-old trained nurse, keeps telling her, “It’s not worth it. It’s just stuff.” He puts his arm around her and leads her out of the house to safety.

He knocks on the neighbour’s door for help. They use the neighbour’s cellphone to call emergency responders who soon arrive. The woman needs immediate medical attention because of smoke inhalation.

Friday, March 29, 2019:  The Saskatoon Fire Department presents Pyra with a Citizen of Merit award and welcomes him into the fire department family.

Saskatoon Fire Chief Morgan Hackl says it was because Pyra remained calm and collected that he was able to use the “short window of safety” to alert his main floor neighbour to the fire and lead her to safety. “He allowed us to have a positive outcome from this incident,” Hackl says.[1]

Thinking, fast and slow

Pyra’s quick thinking in an emergency probably saved his main floor neighbour’s life. To Pyra, it didn’t feel like thinking. In fact, he was quoted as saying that all of his training “went out the window” when he realized the house was on fire. He just automatically did what needed to be done.

That experience of “just doing what needs to be done,” seemingly without conscious thought, is what Nobel prize-winning psychologist and economist Daniel Kahneman[2] would call “fast thinking” or “System 1 thinking.”

For emergency responders, the ability to “just move” – correctly! – is what’s needed in times of emergency.

Thinking fast – “knee jerk thinking” – is deceptively easy. But learning to be capable of accurate fast thinking is not easy at all. In fact, we have to overcome our natural tendency to think fast – and inaccurately. As H. L. Mencken once observed, “For every complex human problem, there is a solution that is neat, simple and wrong.”

In Daniel Kahneman’s best-selling Thinking, Fast and Slow,[3] he identifies two types of thinking which he calls System 1 and System 2:

  • System 1 (fast) thinking operates automatically and quickly, with little or no effort and no sense of voluntary control. (This could be why Evan Pyra felt like all his training went out the window, even though his actions were exactly correct for the situation.)

Kahneman gives these examples of System 1 (fast) thinking:

  • Detect that one object is more distant than another.
  • Orient to the source of a sudden sound.
  • Complete the phrase “bread and…”
  • Detect hostility in a voice.
  • Answer to 2 + 2 = ?
  • Read words on a large billboard.
  • Drive a car on an empty road.
  • Understand simple sentences.
  • Find a strong move in chess (if you are a chess master).

That last item – finding a strong move in chess – demonstrates that it’s possible over time to move from System 2 (slow) thinking, which a novice chess player might experience, to System 1 (fast) thinking, which a chess master might experience.

  • System 2 (slow) thinking gives attention to the complex mental activities that demand it. The operations of System 2 are often associated with feeling in charge of your thoughts, having choice, and being able to concentrate.

The highly diverse operations of System 2 thinking have one feature in common: they need attention. They are disrupted when attention is drawn away.

Kahneman gives these examples of System 2 (slow) thinking:

  • Brace for the starter gun in a race.
  • Focus on the voice of a particular person in a crowded noisy room.
  • Look for a woman with white hair.
  • Search memory to identify a surprising sound.
  • Maintain a faster walking speed than is natural for you.
  • Monitor the appropriateness of your behaviour in a social situation.
  • Park in a narrow space (for most people except garage attendants).
  • Fill out a tax form.
  • Check the validity of a complex logical argument.

In all these situations you must pay attention. You will perform less well, or not at all, if you are not ready or if your attention is distracted.

The gift of System 1 (thinking fast) is that we can do many things automatically. For example, it would be unfortunate if, every morning, we had to re-learn and concentrate on how to brush our teeth. On the other hand, our knee-jerk responses can get us into trouble if they perceive reality incorrectly.

The gift of System 2 (thinking slow) is that we can move past knee-jerk responses that are incorrect and discover new and more helpful responses.

Being of two minds – an ongoing relationship

Have you ever had an argument with yourself? Have you found yourself thinking, “On the other hand…; but on the other hand…”? That’s an example of two parts of our brain doing different kinds of thinking.

Kahneman points out, “Conflict between an automatic reaction (thinking fast) and an intention to control it (thinking slow) is common in our lives.”

He gives examples. We’ve all had the experience of trying not to stare at the oddly dressed couple at the neighboring restaurant table. If you’ve driven during a Canadian winter, you may have memories of your car skidding out of control on ice. You remember how hard it was to follow instructions that are not what you would naturally do. “Steer into the skid, and do not touch the brakes!”

One of the tasks of System 2 (slow) thinking is to overcome the impulses of System 1 (fast) thinking. In other words, System 2 is in charge of self-control.

And the connection to healthcare practitioners is…

Kahneman’s book has multiple fascinating stories and examples of the benefits and hazards of thinking fast and thinking slow. One obvious area that is relevant for healthcare practitioners is in the area of diagnosis. This is especially relevant for healthcare practitioners who are first responders.

In the first few minutes of patient contact, it is crucial – sometimes a matter of life and death – to be able to identify the immediate health challenges of the patient and respond correctly. However, diagnosis is definitely a complex mental process. What’s needed is System 2 (complex) thinking within System 1 (knee-jerk) time.

The best of the best first responder healthcare practitioners can do that. They are like the chess masters who can consider all the hundreds of possible moves and choose the best one.

Except – first responder healthcare practitioners must move through complex mental diagnostic processes quickly, and the stakes are much higher. How do they get good at System 2 complex thinking at System 1 lightning speed?

That brings us to learning psychologist K .Anders Ericsson and deliberate practice.

Deliberate practice – moving from slow to fast thinking – accurately

Ericsson[4] is an icon of peak performance. He developed deliberate practice as a process that allows anyone to develop increasing mastery of critical skills in a chosen area of expertise.

Medical diagnosis is among the many fields in which Ericcson has researched peak performance. A 2015 study that focussed on enhancing diagnostic skills concluded, “…this sort of training with immediate feedback – either from a mentor or even a carefully designed computer program – can be an incredibly powerful way to improve performance.”[5]

To greatly oversimplify, one can move from novice, to competent, to expert to mastery by…

  • Identifying specific skills involved.
  • Practicing a desired skill.
  • Receiving immediate feedback.
  • Identifying strengths and weaknesses.
  • Practicing areas of weakness until they are strong.
  • Gradually increasing the level of difficulty.
  • And so on and so on until…
  • Desired level of expertise and then mastery is achieved.

Through deliberate practice, healthcare practitioners can get better and better at recognizing diagnostic cues and their meaning (a System 2 slow thinking task), at faster and faster speeds (System 1 fast thinking).

The catch: opportunities for deliberate practice

It may not be easy for healthcare practitioners to find opportunities to use deliberate practice to enhance their diagnostic skills. It would be unethical and dangerous to “practice” on live patients, and simulation training facilities may not be easily available.

Hone Virtual Education has created a resource that makes possible deliberate practice of diagnostic skills during the first few minutes of patient contact, wherever and whenever you wish. Hone Cue Recognition virtual training is a series of simulation training modules that you can download to your augmented-reality smartphone or tablet. You can deliberately practice as often as you wish, whenever and wherever you wish, until you achieve diagnostic mastery in the immediate assessment phase of first contact with patients.

Find out more

At www.honevirtualeducation.com you can…

Learn more about Hone Cue Recognition simulation training.

Be notified of updates and launch dates.

Apply to be a beta tester as new modules are developed for health practitioners in high pressure environments.

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Bonnie Hutchinson is a writer and lifelong learner with degrees in Education and Whole Systems Design as well as extensive training and experience in adult learning and teaching. As an organizational and evaluation consultant, she’s worked with many healthcare and healthcare practitioner organizations. She’s bestselling author of Transitions: Pathways to the Life and World Your Soul Desires.

 

[1]  Morgan Modjeski, “Saskatoon man honoured for alerting woman to house fire,” Edmonton Journal March 30, 2019, p. A8.

[2] Kahneman, Daniel (2013), Thinking, Fast and Slow, Farrer Straus and Giroux, New York NY USA.

[3] Kahneman, Daniel (2013), op. cit.

[4] Ericsson, K. A. (2016) Peak: Secrets from the new science of expertise. Eamon Dolan/Houghton Mifflin, Harcourt, CT, USA.

[5] Ericsson (2016) Op. Cit.

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