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Cognitive Strain

February 2, 2015

The doctor-patient relationship is complicated by the fact that both doctor and patient are human, and thus have two parts to their brains.  Many of you will be familiar with Daniel Kahneman’s book Thinking, Fast and Slow.  Kahneman, along with Amos Tversky and others, has done some of the seminal work in the area of decision-making.  Fast thinking, which he calls System 1, is the part of your mind where you automatically identify objects and situations based on your internal map.  It is automatic and none of us has a sense of voluntary control over it.  For example, System 1 allows you to judge distance, detect mood in a voice, recognize faces, and talk while driving (although the last one came with a glitch in my case).  System 2 is the slower part of your brain.  You pull it in consciously when something you’re seeing needs interpretation or is unfamiliar.  You use System 2 to do higher-order math, read Shakespeare, solve word puzzles, and focus on a particular voice in a crowded room.  Kahneman says:

“I describe system 1 as effortlessly originating impressions and feelings that are the main sources of the explicit beliefs and deliberate choices of System 2. The main function of System 1 is to maintain and update a model of your personal world.”  Most of the time the two systems agree.

Here are some of the ways System 1 thinks:

1. It generates the most likely context for an unfamilar event.

2. It has no understanding of logic or statistics.

3. It is impulsive and houses illusions.

4. It jumps to conclusions.

5. It cannot make complex comparisons.

6. You can’t shut it off.

All of this is fine and works great as long as System 2 is there to agree with System 1, or to override and integrate System 1 thoughts when necessary.  Here’s the problem:  System 2 is prone to Cognitive Strain.  It gets tired.  Holding two or more things in your mind that require separate actions or have to be combined in some way is hard.  Following rules, comparing objects on several attributes, and making choices between options, things that only System 2 can do, is tiring.  When our brains undergoing cognitive strain, System 1 has much more influence.  Cognitive strain causes us to be vigilant and suspicious, less intuitive, less creative, and generally uncomfortable.  When we are engaged in a prolonged mental effort we can become effectively blind to everything that does not concern the problem we are working on.  This, I think, is why my 3-year-old is a perfect angel at school and falls apart into a screaming mess the second the school door closes.  Her System 2 is tired from the effort of following the rules and managing her desires in the context of her classmates’.

There are few situations more prone to causing cognitive strain than illness and hospitalization.  Trying to understand new vocabulary and relate it to yourself or your loved one is cognitively hard.  Making sense of an environment in which System 1 doesn’t have any available context is cognitively hard.  Dealing with pain and fear is cognitively hard.  All of these things take away the attention of System 2 and let System 1 run more or less unheeded.  Most people are able to pull enough attention back to System 2 so that they are able to function appropriately, maybe partly because for most of us social norms are deeply ingrained.  But not everyone can.  Thus patients and families can come across to doctors as suspicious, angry, impulsive, argumentative, or downright illogical.  Prolonged cognitive strain can cause people to jump to conclusions and act impulsively.  This is why people can cling to a belief long after science, or facts, or statistics, has proved it to be false.  Steve Pasceri’s cognitive strain is what killed Michael Davidson.

Let’s not forget that doctors are human also.  Many of them are under constant cognitive strain themselves.  Doctors in training, called Interns and Residents, have perhaps the most cognitive strain.  The thinking is that constant mental fatigue pushes medical decisions into System 1’s domain, where responses become automatic.  Residency might make decisions automatic, but it also tends to turn nice, caring people into angry, unsympathetic souls.  Older doctors get similar strain from the demands of the system and also, sometimes, the demands of their patients.  This can make them blind to all but the what they consider the most relevant details in their own problem set.  This is why patients complain that doctors don’t listen, or are unsympathetic, or cold.

My point is that although everyone has a different mental model, a different set of perspectives, we all have minds that fundamentally work the same way.  Understanding our mutual System 2 overload can make communication much more effective.

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