What ultimately separates a good clinician from a moderate clinician? Does it come down to experience or training? Does it come down to knowledge base? In my experience, it ultimately comes down to the quality of our thinking. We think at different levels and we think, often times, with old programming. An elephant is chained to the ground with a spike and a chain around his neck. An adult elephant could clearly pull down a circus tent, yet the elephant learns to not fight against the chain. They learn this as a baby elephant, when the elephant pulls against the spike and realizes that they cannot change their situation. Therefore, they never fight the chain. As the elephant gets older though, they never challenge their assumption.
Thinking evolves. We learn it as a child, we get modified through schooling and adult education, our parents and the influence of our friends, social media and TV. We develop systems of thinking and we take that system and apply it to medicine. Often times, that thinking is faulty. An advanced clinician learns to think about their own thinking. They think about the decisions that they make and why they make those decisions.
I’ve spent the last 20 years evaluating my thinking. I evaluate how I think about certain problems or clinical situations and I often question my own thinking. That’s called metacognition. Metacognition is thinking about your own thinking. There’s a book called The New Earth by Eckhart Tolle. Eckhart speaks about who we are in essence. He suggests that we are not our thoughts, our feelings or our emotions. He suggests that we ultimately are the person who thinks about those things. For advanced thinking, you need to pause and question the program that produces your thoughts.
This newsletter’s going to explore that. In no way do I feel like I can ultimately change people with this newsletter. My hope is to make this newsletter a catalyst for your thought. When I first started approaching cognitive thought it was under the guise of making a lecture on medical errors. There was a body of literature about why we make mistakes and our faulty thinking. I studied that literature strictly to make a lecture on medical errors. As that lecture content grew and I became honest with the application of that content I realized I was making cognitive errors frequently both in and out of medicine. It was a humbling journey because at first, I’d study a cognitive error and realize, “Wow, I do that” and then I would realize, “Holy cow, I do this all the time.”
Thinking Fast and Slow
In the book Thinking Fast and Slow, Daniel Kahneman suggests that we have two levels of thinking, a system one and a system two level of thinking. I subscribe to that philosophy and believe it’s accurate.
System One Thinking
System one thinking is analogous to the radar on a submarine. It’s always working; it’s always looking around; it’s always looking for something to blip on the radar. That’s our intuitive thinking. It’s our first impressions, our hunches, our gut reactions to things. It’s whether you like a song or if the room is too hot or too cold, or if when you walk in the room you like a patient or not. All too often, we make a judgment decision based on system one thinking and believe it’s gospel and don’t question it. That leads to a lot of errors and faulty thinking. Our level one thinking is affected by our biases, our prejudices and our feelings at the moment. This is an instinct to make split decisions about like and dislike and was once linked to survival of our species. Now, as much as it’s necessary for survival, system one thinking can lead you astray when it comes to clinical medicine. Oftentimes we go through the motions when we become experienced and we don’t question what we are seeing and that’s where medical errors happen.
System Two Thinking
System two thinking is much more analytical. It’s analogous to raising the periscope on a submarine to look at whatever bleeped on the radar. It’s proactive and it takes energy. As you’re reading this newsletter, if I asked you, “What’s 13 times 17?” You’d have to pause and try to do some math. If you’re like me, you probably immediately said, “Where’s my cellphone?” to do the math on your cellphone. But if you tried to calculate a semi-complicated multiplication question, you would have to slow down and change your thinking drastically. That’s level two thinking. That’s what we should do oftentimes when a patient’s in front of us when something’s not normal. When something jumps out as abnormal, we need to immediately switch to system two thinking. The problem is, system two requires energy and oftentimes we are too lazy to embrace system two. System two thinking takes practice. It takes formulating a differential diagnosis and a plan.
If I asked you how you could be better at medicine, how would you answer that? What’s one area of medicine you feel a real deficit in? I’ll admit that I feel my neuro exam isn’t very good and I feel my muscular skeletal exam could always use a little bit of work.
But if I asked you how could you be better? If you make small incremental changes in your medical knowledge, sure you’ll get better. If you make changes in how you think, you will make quantum differences.
Contempt Prior to Investigation
I want to quote Herbert Spencer, who said, “There is a principle which is a bar against all information, which is proof against all arguments, and which cannot fail to keep a man in everlasting ignorance—that principle is contempt prior to investigation.” Now, I thought about what he said: contempt prior to investigation. The word contempt means anger and disgust. So, anger and disgust prior to investigation means that I made up my mind in a negative way before I even got all the facts. Once I realized that that’s a philosophy and concept of thinking, I realized how often I did that. I became repulsed by the thought of making up my mind before I looked into all of the facts.
I became absolutely committed to never falling into that trap again. I want to challenge you to do the same thing. If you ever walk into the room of a patient and immediately don’t like them, that says you’re stepping on a trap. If you ever hear someone honk behind you and you look at them with this kind of seething contempt, you need to pause and realize you don’t understand their circumstance. You don’t understand why they’re honking or what their stress level is. Once I realized that I am no longer going to live a life of contempt prior to investigation, it became a lot calmer. I don’t judge so quickly and I challenge you to do the same thing, especially when it comes to patient care.
Practicing Fiduciary Medicine
The term fiduciary is used often in clergy and legal engagements. Fiduciary means an ethical relationship of confidence and trust. When I bought my last house, we had a fiduciary relationship with the attorney, meaning that the attorney’s job was to look out for our best interest and no one else’s. I didn’t want him making any extra money on the surveyor or the new incoming homeowner. I wanted him to look out for our best interest. We need to have that within our medical practice. An ethical relationship of confidence and trust. That’s absolutely mandatory and patients demand it. That means that we cannot be looking out for our best interests. It has to be their best interests. We have to look out for what’s best for our patients and not us. It’s not about our own convenience, it’s not about billing, it’s not about a supervising or collaborating doc. A fiduciary relationship means that if the patient comes in to see me, I have full responsibility for their care.
Too often I didn’t do that. Too often I was more out for my own convenience of moving the patient quickly or time restraints. It was in a phase of my clinical practice where I just didn’t understand that my thinking was faulty. Please use this newsletter to remind you that advanced thinking for our patients’ best interest is key to optimal performance. When we do that thinking, we have to do it in a fiduciary manner, this ethical relationship of confidence and trust. I want this newsletter to be a catalyst that helps you start thinking about your own thinking. Are you practicing fiduciary medicine?
Stay Tuned for Next Month’s Newsletter
In the next newsletter, I will talk about the most common cognitive errors that are made. This has been well studied and talked about. The Harvard Business Review often evaluates thinking errors, because while clearer thinking is critical in medicine, it’s essential in business. A faulty business decision can cost millions or even billions of dollars. This newsletter is prepping you for next month’s newsletter on how we think and why we think, because the why we think is a fiduciary relationship.
I can absolutely guarantee you something. If you commit to changing your thinking to pull against the chain that’s around your neck of cognitive thought that was programmed in you as a child, it will open you up to a much deeper level of understanding of not only patient care but also, the dilemmas you’re going to face in your life. That is my experience.