Clinical Reasoning: Thinking Fast and Slow

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    • #8539
      AJ Lievre

      Check out this video that the clinical reasoning consortium has on the different types of thinking. While watching this, can you relate specific patient encounters where you were accessing system 1 or system 2? Does it make more sense why certain patient encounters seem easier than others?

      For a more detailed understanding of the different types of thinking here is a great read while you are quarantined

    • #8545

      Initially when I graduated I was all system 2 then as I got more comfortable I shifted to system 1, and now that I’m in residency I’m back in 2 most of the time. I think those “I got this,” “slam dunk” type of patients have us in system 1 but we need to be careful to know when to switch back system 2. I think I’m sometimes guilty of ignoring some of those “triggers” that should cause me to go back towards system 2, and then I try to stick it out in system 1 for too long.

      I think our clinical reasoning helps us avoid biases as best as possible by ruling in instead of out, casting a wide net initially, and really thinking about our thinking while treating patients.

    • #8552

      A specific example of use of both systems-
      I had a patient that presented with a lateral ankle sprain and was able to use a lot more system 1 thinking and pattern recognition to guide my subjective and objective examination. However, when things were not progressing as I had experienced before in similar cases and based on my expectations for this patient I had to shift to a more system 2 type approach and further problem solve as to why this could be.

      I think in general I am still very much a system 2 thinker but can see how important reflection in and on action is to shift thinking and develop clinical patterns. I think as new practitioners it can also be easier to fall into more bias when utilizing system 1 and harder to recognize this bias sometimes too. So, while it is not always the most efficient, I think developing a solid system 2 vs rushing the “shift” is important.

    • #8563

      The part of this video that spoke to me most was the highlight of biases. I find myself in premature closure frequently in an effort to move to treatment and convince myself that I have a better idea of what is going on than I do. In this way I need to improve my shift to system 2 to complete my entire evaluation and understand the details I am missing, or at least prove that they are not there.

    • #8584
      Steven Lagasse

      This video brings to mind a specific patient encounter that I had with a student. During an examination, the patient was complaining of unilateral low back pain. She identified her pain by pointing at her right SIJ aka Fortin Finger Sign. The patient’s subjective examination also fit SIJ dysfunction. Working in a system 1 fashion, I explained to the student my prediction of SIJ dysfunction and that an SIJ cluster would likely be positive.

      Moving into the objective exam, lumbar active and passive ROM was negative. I had yet to reproduce symptoms, however, thinking fast, I decided to skip lumbar quadrants and move right to the SIJ. The cluster was negative across the board. My prediction was dead wrong. This quickly made me snap into system 2 thinking. I moved back to the lumbar spine and performed a more rigorous exam, to which a back right lumbar quadrant reproduced the patient’s familiar symptoms. What was initially an SIJ dysfunction became lumbar facet – the rest of the exam went smoothly.

      After the encounter, my student and I spent time reflecting. This experience allowed for a nice discussion regarding systems 1 and 2 thinking, as well as the importance of making predictions, committing to a hypothesis, and performing a thorough examination. Further, the importance of not being afraid to go back to your differential list when the signs and symptoms are no longer matching your prediction/hypothesis.

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