Process of Thinking & Decision Making : Part III
7. Stages of Medical Thinking and Diagnosis
“Listen to your patient carefully,
he is trying to tell you the diagnosis,”
Dr. Wm Osler.
When a patient comes to see a doctor for his/her medical problems, medical thinking begins immediately and, goes through several dynamic stages and steps which means that doctor, by using different thinking modalities, could go back and forth between these steps, in order to clarify some points, to ask more questions to the patient, if necessary.
The 1st step is, to collect data about the patient and patient’s illness, by using classic data collection methods of ”history taking, physical examination and routine laboratory studies”.
The 2nd step is, to review all the abnormal findings with a critical eye , suspicion and critical thinking skills by asking himself the following questions:
Does the patient has any reason to lie? Are my physical findings correct? Are there any lab errors? Are all these abnormal findings compatible with the patient clinical presentation?
Any suspicious findings should be double checked and suspicious lab studies should be repeated.
The 3rd step is, to analyze all these abnormal findings with analytic thinking skills , medical knowledge and experience, as to what do they mean and, which organ damage, with what kind of mechanism caused these abnormal findings? In medical jargon this is called “pathogenetic mechanism of the disease”.
The 4th step is to synthesize all these abnormal findings in to a single or multiple disease concepts ,if patient has more than one disease( comorbidity).
The 5th step is to prepare, what is called, ”illness script” or disease scenario, by describing who is the patient, how where and when he/she got sick, how sick is the patient, what are the most striking abnormal finding in patient’s history, physical exam or laboratory studies?
The 6th step is to prepare a list of diseases that must be considered in differential diagnosis. For this, I pick the most abnormal finding and check my memory, or ask Google or ask the computer that is programmed for “computer assisted diagnosis”, to list the diseases that present or share this most abnormal finding.
The 7th step is to eliminate diseases with deductive reasoning if they do not share and explain all the findings described in the illness script.
The 8th step is to verify the final diagnosis,if necessary by doing advanced testing and, to prepare the treatments, follow up and prognosis plans.
8. Clinical Thinking and Nature's Laws
In nature everything happens with a cause and “cause and effect relationships”, within a time frame. Diseases also occur with a cause and, cause and effect relationships, within a time frame. Diseases induce some damages to the body. Body perceive these damages as “action”, and shows its “reaction” to them with compensatory mechanisms and immune system. In addition, patient seeks medical care and treatments. All these measures are considered reactions to the action of the disease. Thus, it becomes obvious that, there are clear relationships between nature’s laws, medical thinking and time. These relationships are summarized schematically below.
Clinical Thinking, The Law of Nature and Time relationships.
9. Different Systems of Thinking in Motion, with Case Presentations
Medical thinking and decision making, as we discussed earlier, is long ,difficult, slow, deliberate and requires energy (human brain uses 20% of its energy on thinking) and the help of higher mental faculties. But this type of thinking is impractical in daily life. There are other types of thinking and decision making that are faster, practical and energy efficient. But they are not always error free.
Eminent ,Princeton University psychologist ,Nobel Prize winner in Economic Sciences Dr. Daniel Kahneman, in his most important book, ”thinking, fast and slow”, which is considered by many, as a masterpiece, have addressed brilliantly these different systems of thinking and styles. I urge every reader who is interested in human mind and thinking, to read this important book.
According to Dr. Kahneman, generally, two systems of thinking drive our mind and our thinking. The slow, deliberate and more logical thinking which is called “system 2 thinking”. This style of thinking is long, difficult, tiresome, energy and willpower requiring. For this reason, it is not liked by many people. On the other hand, there is a fast, intuitive and emotional thinking that requires little or no thinking and no energy expenditure. This is called ”system 1 thinking”. System 1 and system 2 thinking, work independently of one another. Usually, system 2 does not know what system 1 is doing, unless it’s help is asked But when system 2 thinking is in charge, all reflex motions and intuitive thinking stop and higher mental faculties are in charge of thinking.
Let’s see some cases of thinking in motion. A fire chief with 30 years of experience behind him, while trying to extinguish a hose fire with his crew, suddenly feels uneasy. Orders his fire crews out. Re- evaluate the situation and found out that the fire started in the basement, but they were trying to put out fire at the first floor.
A grand chess master while walking through a street chess tournament, without even stopping, says,” the whites will take the king in three moves” . Indeed that is what happens.
In case of a medical emergency, ie, a patient with massive intestinal bleeding and hypotension comes to ED. Doctor has no time to think, to establish the cause of bleeding. His training and experience induced instincts take over. He immediately puts the patient in Trendelenburg’s position, starts IV and give large volume serum and blood transfusions ,admits the patient to ICU. After patient’s clinical condition is stabilized, then he start to think how to establish the cause of bleeding.
A clinical study done on very busy (who sees 60 or more patients daily), astute, competent and experienced doctor’s office practice, by videotaping with them with their permissions but without knowing when, clearly showed that in 80% of patients, the diagnosis were made within 2 minutes, by using system 1 intuitive thinking. System 2 thinking is used only 20% of the time.
These are the examples of system 1 thinking at work. They all have one thing in common: an intelligent and able person with necessary training, many years of experience and repeatedly doing the same thing.
The fire chief has 30 years of fire extinguishing experience behind him; the grand chess master, besides possessing a very high ”chess intelligence”, in order to become chess master, he had to study every chess moves very seriously ,for at least 10,000 hours. This means that he has to study chess, with full attention and every day for 5 hours, for 6 year duration. Experienced practitioner doctors, besides being intelligent, energetic and working hard, have 15 to 25 years clinical experience behind them.
It is obvious that only selected group of people with certain personality characteristics such as intelligence, hard work, vast experience and countless repetitions of the same thinking and doing process, could develop system 1 intuitive thinking and decision making abilities. As I see it, human’s mind and body with its infinite wisdom converts these repetitive, energy requiring, difficult attempts in to a more efficient, subconscious and intuitive reflexes that require very little or no thinking and energy expenditure.
In medicine, system 1 intuitive thinking and decision making takes different forms and names. Among them heuristics, pattern recognition and automatic reflex movements of acquired skills are used most of the times. The details of these concepts are beyond the scope of this article. I will refer my Turkish speaking readers to read my book, ”Klinik Dusunmenin Temel ilkeleri”, on this subject for details.
Then, we must ask an important question here, ”what is the role of instinct, sixth sense or gut feelings, in decision making?” We all have them, they require no training, no experience and no logical rational?” I will address these issues in one of my future articles.
10 . Why Do Thinking Produce Emotion First That Effect Our Decision and Behaviors?
“the ancestor of any action is taught”.
-Emerson.
Human brain is a miraculous anatomical and functional organ. It has evolved continually, over billions of years of evolution. Consequently our brain contain three different evolutionary systems. The triune brain model (3-in-1), was proposed first ,by America neuroscientist Dr. MacLean in 1960. The first part of the brain is primitive reptilian brain complex; the second part is mammalian( or limbic) brain complex; and the third part is neo mammalian (or neocortex) brain complex. All these structures sequentially added to the forebrain, during the course of evolution.
The reptilian brain is seen exactly in to days reptiles and birds. It is responsible for species-specific instinctive thinking, behaviors such as aggression, fear, flight, territorial dominance.
The mammalian (or limbic) system arose early in mammalian evolution, is composed of set of interconnected brain structures (such as septum, amygdale, hypothalamus, hippocampus and cingulate cortex) that are major functional systems. In addition, mammalian brain is responsible for emotions and feelings that involved in feeding, reproduction and parental behaviors.
The neo mammalian (or neocortex) system is regarded as the most recent addition in the evolution of the brain. It consist of two larger cerebral cortex which is found uniquely in higher mammalians like primates and humans. It is responsible for higher mental faculties, creation of mind, thinking, language, alphabet, consciousness ,logic, imagination, invention etc.
The Triune Brain Theory is not accepted by the majority of modern neuroscientists. It is over simplification of human’s brain, and it is only good for teaching purposes.
Thinking process in humans, especially intuitive thinking is hard-wired to the primitive parts of the brain system that provoke emotions, first. This is a remnant of evolution but as Homo sapiens we should be aware of these unavoidable emotions and control our emotional decisions, by using our higher mental faculties.
11. What is The Role of Our Mental Environment on Our Thinking?
“I am a human being ,anything belong to human
beings is not strange to me”
-Terence (BC 185)
The aim of thinking is to find the truth, nothing but evidence based truth. The truth matters. It affects us all. It helps us to understand and to see the real things behind cover-ups, lies, misinformation and fake news.
Thinking takes place in our mental environment. In order to think objectively we must have a mental environment that is neutral, not polluted with prejudice, bias, discrimination, racism, religious fanaticism, homophobia, misogynism etc. These elements overshadow reasoning and finding the real truth.
Nobody could have a completely neutral mental environment at all the times. But we can have an open mind and beware of the state of our mental environment and our emotions, while we are thinking and making decisions. This process is called, ”metacognition”.
As human beings, we are all created genetically different. Creation of different species and differences between species is one of the most prominent nature’s law. Without it, life would have become boring. Therefore differences among us are unavoidable and they are good for the species.
Without believing in science, scientific education, thinking principles and always paying attention to the truth, having an open mind to rational tolerance, to our differences and our diverse point of views, no society could become an advanced civil society.
12. The Joys and Perils of Too Much Thinking
“Sapere Aude!”
-Kant.
Thinking is the best way to discover who we really are. Only thinking will make us thoughtful, wise and respected. One must have enough knowledge, courage and determination to do the hard work of thinking. That is why most people, instead of thinking, prefer to be told what to do or make their own decisions intuitively, without thinking. Thinking is the only way to know more, to learn more and to understand more. There are close connections between thinking and intelligence, love of learning and, believing in positive sciences. Thinking person can not be fooled as easily as none thinking person, by lies or fake news.
Every person is unique in his/her thinking, because every person has his own genetic makeup, his innate talents and life experiences. That is why every person’s opinion is different and valuable. We all should learn how to think better, for our own future and for the future of the world and humanity.
However, sometimes thinking too much, can paralyse us. We can not decide what to do, which options to choose. This is called, ”paralysis in analysis”. And, sometimes cold facts alone are not enough to make a decision. In these situations, we need to trust our instincts and our emotions. Emotions are like two edge sword; on one hand, they overshadow reasoning and decision making, on the other hand, they help to make difficult decision.
For this reason, trying to control our emotions all the time, for the sake of a rational decision, is not always a good strategy. It could make us cold, flat, uninteresting person. The better way is, to be aware of our emotions, to keep them under control, but show them, only at the most appropriate times.
13. What is “GUT FEELINGS“ and How Do They Affect Our Decisions?
As I see it, “gut feelings“ is an inner voice, an intuition that provide guidance to make a decision without any conscious logical rational.
Our brain, being a miracle organ, continuously obtains, decodes and interpret information, from every cell, every tissue and organs in our body through the massive neural network and via the electrical current, chemical signal molecules and different hormones. Cognition of these information leads to feelings. Feelings are used in decision making. Our brain uses two different thinking styles as mentioned before. System 1 is fast, uses just thinking to make subconscious, intuitive emotional decisions. In system 2 thinking, the brain uses combination of feelings, knowledge, experience and logic to make a slow, deliberate and rational decision.
Since our brain continuously obtain information from every cell in our body, it is inconceivable that our brain will ignore information from some 300 billion of microbes that live in our gut. These microbes consist of bacteria, viruses, yeasts and parasites. They are called “gut microbiome or microbiota community”. They are metabolically very active, live in a friendly manner (symbiotic) in our guts and feed on food particles that we consume. They produce many useful functions for the host. They help to digest certain food substances, produce many hormones, vitamins, signal molecules. They help to regulate body’s immune system and protect the host from invasion by pathogenic bacteria.
It is impossible to think that our brain will ignore this many useful cells. There has to be brain- bowel- microbiome connection and communications. I believe that “gut feeling” originates in the gut microbiome community first and then send to the brain for cognition and expression as “gut feeling”.
A new theory of feelings and emotions has to be envisioned that includes gut microbiome community and their signals to explain gut feeling and possibly why coward people often called “they have no guts”.
