The date is May 31, 2009. Air France Flight 447 left Rio de Janeiro, on its way to Paris, with 228 souls on board. This plane was really spectacular because of how automatic it was. The pilots could get in, take off, and once they cleared the departing airport, the plane more or less did the work. All’s well and good.

The two pilots on Air France Flight 447 most likely went into a passive mode because they thought, “Ah, well, the airplane is going to fly itself.” But there was a minor problem with what’s called pitot tubes. The pitot tubes send speed and air direction to a plane’s computers. From time to time, they freeze up. When this happens, alarms go off and knock the plane out of automatic pilot.

This unfortunately happened during this flight. All of a sudden, these pilots had to go from a passive way of thinking into a very active way of thinking. When that happens, we can enter a cognitive trap called cognitive tunneling. We focus on what’s in front of us and maybe over correct.

Have you ever been driving passively and, next thing you know, you’re driving under a light as it turns yellow? All of a sudden, you snap out of your passive mode and begin actively driving, but you overcompensate. You hit your breaks and kind of jolt your car. Well, that’s what happened here.

The pilots started tilting the nose of the airplane up, thinking that would compensate for the problem. However, that can put a plane into what’s called a stall. The lift of the plane started going up, putting the plane in tremendous jeopardy. The captains couldn’t recover from this lift. They kept trying to figure out what the problem was, but because the pitot tubes were frozen, they couldn’t get proper data.

When the captain finally realized what was happening, it was too late. The plane crashed into the ocean and everybody on board died. Investigators tried for two years to figure out what happened. Only when they recovered the voice recorder could they piece together the tragedy.

All of this tragedy because of cognitive tunneling.

Passive vs Active Thinking in Medicine

As we practice medicine, especially emergency medicine or critical care, when someone’s life is on the line, we have two primary ways of thinking: passive and active.

Daniel Kahneman wrote a book called Thinking Fast and Slow. It’s an awesome book if you want to understand how we think. It’s a hard book to read because it reads like a textbook, but it does a great job of teaching these two major concepts.

I’d like you to think of a submarine going through the ocean. The submarine has to watch out for things around it, so it puts on its radar and the radar keeps going and going. Everything blips on the radar. The radar is a passive way for the submarine to pay attention to its surroundings. If the crew sees a blip on the horizon, the captain puts up a periscope and focuses on exactly what caused the blip. While the radar is passive, the periscope is active.

We think the same way. We have level one and level two thinking, or as Daniel Kahneman refers to them, system one and system two. Our “radar” thinking is constantly searching the environment. This is our intuition, our gut reaction. I ask you, “Is the room warm or cold?” You’ll have a visceral response to that question. It won’t take any energy whatsoever to answer it.

What if I asked you, “What is 13 times 6?” If you want to really try to solve that, you have to immediately use a different level of thinking. You have to put your periscope up and really focus on the question.

The problem with our brains is that we were designed for survival and to conserve energy. Lazy, system one thinking is how we operate most of the time. That serves us well; it makes us very efficient. We come up with mental shortcuts within system one thinking. If we work in emergency medicine, we call those heuristics and they make us very efficient.

The problem arises when something deviates from our heuristics and we have to snap into periscope thinking. We have to focus on the problem in a detailed way that makes us take more action.

Shifting from Passive to Active

I believe one of my biggest assets as an emergency medicine PA is my ability to shift from a passive state to an active state. I can walk into a room and recognize a pattern, whether it’s a pulmonary embolism, acute coronary syndrome, a peptic ulcer or a septic patient. We form these models or patterns in our head and look for them in patients. But if something isn’t following the pattern, we have to stop, focus, reset our thinking and start from scratch.

One of the things I found working in the ICU is that a nurse’s intuition is a highly sensitive test. If an experienced nurse says to me, “John, come see this patient, something’s wrong,” there is always something wrong. They were doing a general assessment and because they’re a seasoned nurse, they have a pattern in their head of what a normal patient should look like. When the patient deviates from the pattern, the nurse says, “Something’s not right; I want you to come see the patient.”

This intuition takes time to develop. In my experience working with other clinicians, it takes about three years. That’s why a lot of residency programs are three years. It gives you time to get enough patients under your belt and realize what normal looks like.

What determines your your ability to switch from passive to active thinking? To a huge degree, it’s your paradigms and how you look at your clinical practice. Too often we get complacent and stay very passive. That’s when we make mistakes. That’s when we don’t see slight deviations from the pattern and don’t take the next step.

As a new graduate, I had a bias toward benign. When I saw a patient, in the back of my mind, I’m thinking, “This is okay; this is going to be nothing.” I had a couple of near misses and realized that this bias toward benign made me lazy. Now, I have a bias toward bad. I’m always thinking bad things are going to happen with my patients. I’m constantly looking for deviations from the pattern.

I’ll never forget a 78-year-old man who I was called to admit for chest pain. He absolutely had some kind of acute event during dinner with his wife. There was a significant onset of chest pain, he became diaphoretic and they came to the ER. There, he had a normal workup and we wanted to admit him to rule out acute coronary syndrome. He had a non-specific EKG, normal troponins and normal biomarkers.

So, I went to see this man. At this point in my career, I had seen a whole bunch of acute coronary syndrome. I had a clear pattern of what an acute coronary syndrome patient looks like. But I got into the habit of documenting what the ER did for the patient. What medications they gave, etc. I remember exactly where on this man’s chart I wrote this, on the back page of my history and physical, on the top left.

I realized this man was given a liter of fluid in the ED for blood pressure support and he was borderline hypotensive with pressures in the 90s. I asked, “How’s your pressure normally?” He tells me it’s 120/80 and that he checks all the time. I don’t think that makes sense because he hasn’t had any ongoing pain. If he had acute coronary syndrome that made him hypotensive, he’d look pretty sick due to cardiogenic shock.

On his physical exam, he had some rails in his left base, almost sounding like pneumonia, but there was no fever or white count. None of this fits my acute coronary syndrome pattern, so I went and looked at the chest x-ray. Portable chest x-rays always have a widened-appearing mediastinum; it’s a bad screening test, but it still looked wide to me. This just didn’t fit the pattern of acute coronary syndrome.

I talked to the night nurse and asked her to move this patient to another building for a CAT scan. I felt so bad because it was a hassle to get a CAT scan at night. I helped the nurse push the patient over for a CAT scan because I knew something wasn’t right. A half hour later, I’m back in the ER and I get a call from the radiologist. He says, “John, this man has a type one thoracic dissection.

Making the Shift

You have to learn to control your focus. Am I in a passive mode or an active mode? How do I know when to change my focus? You have to form mental models of what a normal patient looks like. What does a pediatric patient with moderate respiratory distress look like? Can you picture it? You’ll send home a soft chest patient, but what does that patient look like and how do you document it?

You can’t stay in passive mode all the time. It’s also unrealistic to think people can stay at level two thinking all the time. They would be absolutely exhausted at the end of the shift because the body and mind are designed to conserve energy. I go see a patient and at times I’m very passive. However, I’m constantly looking for reasons to pop out of passive mode into an active mode of thinking. What makes a good clinician is knowing when to make the shift.

The best way I can help you understand how to make the shift is to just be aware of it. Be aware that you have to go from passive to active thinking. When a nurse or a patient brings you new information, that’s the time to go into active mode. I can tell you from experience, in order to be sharp, you have to be optimal when you start your shift. You need to get good sleep, be hydrated and leave emotional burdens at home. Otherwise, you’re going to settle into a passive way of thinking.

This is where heuristics, mnemonics and checklists are very important. When a pilot gets on an airplane, they follow a checklist every time. When you’re working up someone with chest pain, shortness of breath or abdominal pain, you need to have a cognitive checklist so you don’t get burned.

I hope this newsletter is a catalyst for your thinking. A good clinician is always looking at their performance. In medicine, it’s easy to make technical advances but harder to make paradigm changes. Thinking about your thinking, or metacognition, will give you the most optimal growth.

On your next shift, realize whether you’re in a passive thinking mode or an active thinking mode. What’s going to snap you out of a passive thinking mode? If you see someone with a respiratory rate of 26 on the nurse’s triage sheet, you better snap out of it, because that’s not normal.

I’m going to challenge you to be focused on your next shift. Are you in a passive or active thinking mode? Are you thinking critically?