- Indian Rheumatology association
The resident working in a busy A & E department was excited. He was going to do his first steroid injection into a knee joint. A 60-year-old man with a history of diabetes, hypertension and gout had presented with pain and swelling in the right knee for 1 day along with mild fever and an occasional cough. A quick examination revealed an erythematous, tender knee with a joint effusion. The resident diagnosed acute gout and prepared to inject corticosteroid. The consultant on call took a detailed history from the patient. He asked the resident not to inject steroid into the knee but only to do a diagnostic tap. He also ordered a chest radiograph which showed a right lower lobe consolidation. Septic arthritis was later confirmed on Gram stain and culture of the aspirated fluid.
This example illustrates the difference between so-called ‘fast’ and ‘slow’ thinking in clinical decision making. These two terms were first introduced by the Nobel prize winning behavioural economist Daniel Kahneman in his book ‘Thinking, fast and slow’ published in 2011. According to him, decision making is the result of two systems of thinking which he called System 1(fast) and System 2 (slow).
System 1 is fast, used often and operates with little thinking. System 2 is slow, needs careful thinking, logic, weighing of options and is used less often.
The importance of this classification lies in the fact that the use of System 1 thinking is prone to errors and biases as it lacks adequate reasoning. In his 2007 book, ‘How doctors think’, Dr Jerome Groopman provides several examples to illustrate these two ways of thinking as used by clinicians.
We, as doctors, make use of both systems in our daily work. In the example above, the resident used fast thinking which led to the incorrect diagnosis. His consultant prevented harm to the patient with a timely slow thinking approach. Fast thinking is what we use when we rely on pattern recognition to make a quick, ‘spot’ diagnosis. When it works, the results appear impressive. But when it fails, it is easy to come to the wrong conclusions. Most clinicians employ slow thinking to solve complex clinical problems whose solution is not immediately obvious such as in the diagnosis of pulmonary aneurysms in a patient with Behçet syndrome.
Decidedly, it does. It is crucial for making life and death decisions in high stakes environments like the emergency department and intensive care units where time is often short and a quick decision can save a life.
The problem comes when fast thinking is used as a quick shortcut, especially when a doctor has to see a large number of patients in a short span of time. This can happen in a busy outpatient department or in an A&E with inadequate staffing. It can then be tempting to make rapid diagnoses and dispense treatment. Unfortunately, things can go wrong for a proportion of patients assessed in this fashion and the results can be disastrous.
Time is the enemy of slow thinking. Those in a hurry for any reason will avoid using it as a default mode. Also, too much thinking can sometimes lead to clinical nihilism and paralysis by analysis.
Rheumatology is a discipline largely suited to the slow thinking approach as patients often do not present with simple, easy to diagnose illnesses.
Give enough time to each patient so that a modicum of slow thinking can be applied to the consultation. Avoid the tendency to jump at the first likely diagnosis without generating a list of differentials. Be willing to review a previous diagnosis made in haste and correct it, if necessary, with greater reflection.
Used appropriately, the fast and slow thinking systems can work well to strike a balance between time spent and efficiency achieved. Just avoid being fast to use ‘fast’ thinking or slow to use ‘slow’ thinking
