Clinical Reasoning: Thinking Fast and Slow

Introduction

• Clinical reasoning involves several component skills.
• Focus on "thinking fast and slow" or "system one and system two."

System One: Fast Thinking

• Characteristics:
  • Relies on intuition and previous experiences.
  • Typically involuntary and uses heuristics (as per Daniel Kahneman).
  • Beneficial for daily activities but can lead to errors if over-relied upon.
• Role in Clinical Reasoning:
  • Experienced clinicians build capacity through experience and pattern recognition.
  • Use scripts to chunk information and recognize patterns efficiently.
  • Reliance on system one until a situation doesn't fit a known pattern, triggering system two.

System Two: Slow Thinking

• Characteristics:
  • Slow, effortful, and conscious.
  • Better for complex, unfamiliar situations.
  • Considered more reliable than system one.
• Role in Clinical Reasoning:
  • Novice clinicians depend more on system two due to lack of experience.
  • Over time, they transition to more system one thinking but with frequent shifts back to system two.

Common Biases in Clinical Reasoning

• Availability Bias:
  • Prioritizing first thoughts based on limited experiences.
  • Mitigation through research and expert guidance.
• Recency Bias:
  • Giving more weight to recent events, e.g., over-palpating after detecting an anomaly.
• Confirmation Bias:
  • Selectively gathering information to support preconceived conclusions.
• Premature Closure:
  • Ending decision-making prematurely, analogous to the "blind villagers" parable.

Managing Bias and Shifting Between Systems

• Awareness and Education:
  • Recognize and educate oneself on biases to avoid traps.
• Planned Bias Checkpoints:
  • Implement systematic reflection and checkpoints to control biases.
• Reflection in Action:
  • Pause post-interview to consider unthought-of alternatives.
• Reflection on Action:
  • Reflect post-case to improve system one for future scenarios.

Conclusion

• Both systems one and two drive effective clinical reasoning.
• Experts mostly use system one but shift to system two when necessary.
• Systematic bias control enhances the ability to transition between systems, improving clinical reasoning.