Uncovering the hidden layers in a consultation

They say there is nothing more amusingly arrogant than a young man who discovers an old idea and thinks it is his own, but perhaps you’ll indulge me in exploring an old understanding that I’m only recently beginning to appreciate.

In medical school in many ways the treatment of patients seems to be quite straightforward and linear. A leads to B which leads to C. Clearly if you wanted to do things right then starting at A you would always end up at C. 

All pneumonias are treated with antibiotics; in contrast viruses never require antibiotics. Shared decision making with the patient is paramount; you never hide or manipulate the truth from patients, and there should be a clear rationale for all prescribed medications. 

Day after day we process clinical problems with clear algorithms independent and unbiased by context. An outside observer of your notes and clinical approach should easily be able to understand your thought processes and replicate as necessary. 

And yet medicine is not linear. In the situations described above we all have examples where the logical next step was not followed. There is a ‘greyness’ in medicine that could consume those yearning for certainty and objectivity. Believing there is a straight path from A to C is only a superficial understanding. 

One juncture at which the supposedly linear course of medicine begins to fall apart happens right inside our minds, before the patient even begins to tell us what’s wrong with them. Some studies suggest that the majority of misdiagnoses occur, not due to a lack of knowledge or equipment, but due to cognitive errors. 

The popular author Malcolm Gladwell in his book, Blink: The Power of Thinking Without Thinking, writes about the ‘adaptive unconscious’ the subconscious gathering and processing of information that guides many of our decisions. We can make snap decisions about situations with very limited knowledge. A patient’s demeanour, gait and clothes – seemingly distracting and irrelevant details – can lead our subconscience to decisions we wouldn’t consciously consider. 

This is the powerful tool we use on a daily basis to allow us within moments of seeing the patient to be considering already our most likely diagnosis. We can use a combination of age, expressions, mannerisms and opening exchanges to narrow down the possibilities within seconds. 

This is the power that allows us with some confidence to immediately sense a child is ‘sick’ or ‘well’, to detect the subtle signs of psychiatric illness from observation alone, to make what can seem like miraculous leaps of deduction with minimal facts or need for examination. This is what some term as a ‘gut feeling’.

Gladwell goes on to illustrate how this unconscious effort, while usually helpful, can be abused and indeed be quite destructive. We may develop cognitive biases: only considering those diagnoses most familiar or most memorable (availability heuristic), being distracted and fixated on the initial impression or first symptoms (anchoring) or never entertaining unusual or unexpected diagnoses but staying within the limit of our own experiences (framing). 

A more elaborate treatise on these cognitive biases is offered by the Nobel Prize winner Daniel Kahneman in his book Thinking, Fast and Slow, in which he discusses the constant tension between our intuitive (subconscious) and our analytical (conscious) thinking. He further discusses the unstable relationship we have with risk perception. This will be familiar to us in attempting to communicate risk to patients (eg. HRT and breast cancer, raised cholesterol and cardiovascular disease), in which doctors have been proven to be as unclear about the actual potential risk as patients – often innately overestimating the risk.

Despite the years of training, continuing professional development and the increasing role of evidence based medicine, we are still, obviously, using our brains as the main clinical decision maker. Brains which may deceive us may often be corrupted by illogical past experiences and unrecognised prejudices. So when next someone says to you “trust your gut”, you may respond “yes but I’ll question it too!”

The consultation and the relationships we create with our patients have many more layers to be uncovered but this was one old idea I was happy to discover for myself.