Okay, one more Blink-related post (see previous post for introduction to this text). Gladwell seeks to examine the role of snap judgments in the setting of difficult police encounters. He explains that “in interviews with police officers who have been involved with shootings, these same details appear again and again: extreme visual clarity, tunnel vision, diminished sound, and the sense that time is slowing down. This is how the human body reacts to extreme stress, and it makes sense. Our mind, faced with a life-threatening situation, drastically limits the range and amount of information that we have to deal with” (224). However, one can only hope this is how we react to extreme stress. “Dave Grossman, a former army lieutenant colonel and the author of On Killing, argues that the optimal state of ‘arousal’– the range in which stress improves performance — is when our heart rate is between 115 and 145 beats per minute…’after 145’ Grossman says, ‘bad things begin to happen. Complex motor skills start to break down. Doing something with one hand and not the other becomes very difficult…at 175, we begin to see an absolute breakdown of cognitive processing…’.” (225). The absolute breakdown of cognitive processing, what could be more petrifying? As a future ER physician the ability to remain composed, to filter unnecessary outside noise, to perceive with visual clarity and achieve “the optimum state of arousal” is essential to success. It is essential to saving lives. I began to evaluate my own personal abilities in this arena. I have been told by friends and family that they admire my ability to stay calm and focused when the energy of a situation is heightened. But what situations have I truly experienced in which these skills have been properly tested, especially clinically? Shockingly they don’t leave medical students in charge of life-threatening situations too often. Yet, I wondered if I’d had a taste of optimal arousal at 115 – 145 beats per minute during a challenging situation. I guess you could say I’ve had a small glimpse.

It was my third rotation of third year. On our first day of our elective anesthesia rotation my friend and I met with the clerkship director who told us “this rotation is whatever you make it, no one would notice if you weren’t here.” As a fourth year student those were be the greatest opening comments one could ask for, but as third year students my friend and I were hoping for more guidance. This was our first lesson in truly becoming self-directed learners as we shamelessly harassed the anesthesiologists and CRNAs to let us intubate and be involved in interesting cases. Receiving even a molecule of attention was the most difficult part of the rotation — with the exception of the days we chose to practice IV placement with our favorite pre-op nurse, who was wonderful. Each day I would remind my friend that we essentially pay $200 per day for medical school, and I wasn’t going to leave until it was a “$200 day.” For weeks I honed my procedural skills, focusing on beginning to feel competent intubating in a controlled setting. It was my last day of the rotation and I had worked up the chutzpah to ask to do the airway for a case being run by a particularly…intimidating anesthesiologist. I walked in the operating room to find the following cast: a CRNA who had yelled at my friend, the intimidating anesthesiologist (she was migrating from room to room so I didn’t expect her to be there), a notoriously medical-student-unfriendly surgeon with his arms crossed, one of my other colleagues on her surgery rotation, and what seemed like an excessive amount of technicians and nurses. Heart rate climbing — at least 100 beats per minute. “You only get one shot, I don’t have time for this,” remarked the surgeon. Now I was probably around 130 beats per minute. I steadied myself behind the patient’s head with my hand gently upon the non-rebreather mask. I preoxygenated, the anesthetic and paralytic were administered, head-tilt-chin-lift, carefully I scissored open the patient’s mouth and place the blade inside. The patient was stable but I was on the surgeon’s clock and the anesthesiologist’s responsibility. I had placed the blade too deep and I knew it. “I don’t see the chords just yet,” I stated calmly. I could feel the tension build as the CRNA and anesthesiologists hovered behind me. “I’m just too deep, I think I know how to adjust”, I said, seemingly ignoring the surgeon’s “you get one shot” declaration. Extreme visual clarity, tunnel vision, diminished sound, and the sense that time is slowing down. To some degree, I felt this — the whole room was watching, but my world was entirely centered on the intricate anatomy of the patient’s airway. I readjusted the blade up, visualized the chords and slid the endotracheal tube into position. The CRNA listened for breath sounds as I watched watched the CO2 waveform on the monitor and the end tidal CO2 detector change color. “Alright good,” the anesthesiologist remarked as she relinquished a fraction of a compliment with a palpable reluctance. I left the operating room, and met my friend as I was grabbing my bag. “You’re heading out? I guess it was a $200 day?” “It was.”  

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Source:

Gladwell, Malcolm. Blink:The Power of Thinking Without Thinking. New York, NY: Back Bay Books/Little Brown and Company, 2005. Print.

How do you know you’re a nerd? When you essentially end up writing a book report during your free time on a snow day.

I intend to saturate the second half of my fourth year of medical school with an abundance of enriching experiences: travel, new hobbies, old friends, reflections, libations, celebrations, etc. Oh, and of course more writing! I’m currently working my way through my reading list, and I recently finished Malcolm Gladwell’s Blink: The Power of Thinking Without Thinking, which has been on my list…forever (it was published in 2005). For those unfamiliar, this novel tackles the challenging subject of good and bad decision making, and the art of making snap judgments. It is a thrilling ride of endless examples exposing the consequences of “conscious deliberation [versus] instinctive judgment” (269). Ten pages into the book Gladwell describes the Iowa gambling task, which involves participants turning over cards from four decks (two blue and two red): each card either loses or wins the player money, and the goal is obviously to maximize profit. The red cards are essentially a “minefield” with high rewards and high losses, while the blue cards offer a steady payout. The scientists at the University of Iowa discovered it takes roughly eighty cards for the participants to confidently state they understood the pattern — “we have some experiences. We think them through. We develop a theory. And then finally we put two and two together. That’s the way learning works” (9). Participants additionally stated that after fifty cards they had a hunch regarding the pattern; the Iowa scientists explored this idea by hooking each participant up to a machine that evaluated physiological parameters consistent with the stress response. Turns out, the participants began generating stress responses after only ten cards, and then began to change their behavior accordingly. Gladwell inquires ”what does the Iowa experiment tell us? That in those moments, our brain uses two very different strategies to make sense of the situation. The first is the one we are most familiar with. It’s the conscious strategy. We think about what we’ve learned, and eventually come up with answer. This strategy is logical and definitive. But it takes us eighty cards to get there. It’s slow, and it need a lot of information. There’s a second strategy, though. It operates a lot more quickly. It starts to kick in after ten cards, and it’s really smart, because it picks up the problem with the red decks almost immediately. It has the drawback, however, that it operates –at least at first–entirely below the surface of the consciousness” (10). Wow, could these concepts be any more imperative to my future career as an Emergency Medicine physician, I asked myself? Learning to make decisions in the blink of an eye? Of course, the utility of Gladwell’s concepts in the ER setting is by no means a novel idea, in later chapters he focuses extensively on Cook County Hospital’s development of the Goldman algorithm for evaluation of acute chest pain. But needless to say, I was eager to learn more about his theories.  

As I continued to read and reflect I realized how familiar I am with some of what Gladwell is essentially describing — the concept of intuition . For as long as I can remember by mother has always said “trust your intuition” or “what does your intuition tell you?” Even before I could probably spell intuition. I continued to examine the role this has played in my life — had my intuition, my gut feeling, my ability to “thin-slice” (which Gladwell refers to as “the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience”) ever truly failed me? I then began ruminating over instances when the utilization of intuition, thin-slicing and snap judgments had intersected with my career. In considering my EM rotations over the summer I recalled moments, patients or interactions with faculty where I ignored my gut feeling.  As an educated individual this is where I know I should provide specific examples, but my intuition  informs me that these details should remain nestled in my noggin. The point is, why did my reliance on these subconscious decision making skills not always translate to my experience as a medical student? Not to worry, Gladwell had an answer.

While Gladwell fills his novel with an abundance of examples illustrating the capabilities of the human instinct, he certainly does a fair job of acknowledging that “our unconscious is a powerful force. But it’s fallible, it’s not the case that our internal computer always shines through, instantly decoding the ‘truth’ of a situation. It can be thrown off, distracted, and disabled. Our instinctive reactions often have to compete with all kinds of other interests and emotions and sentiments (15).” This struck a chord. Distracted and disabled were accurate descriptions of the state of my instincts recently, and as an individual keen on perpetual self-reflection (oftentimes to my own detriment) I had been searching for clarity in hopes of achieving any degree of self-improvement. It became clear to me that I let the emotions and sentiments of my fourth year overpower my developed ability to decode the “truth of the situation,” a skill that I was certain to be a strength in my personal life. Gladwell opens Blink with a powerful example of the experience of Getty curators in their controversial pursuit to identify the authenticity of Greek sculpture — many experts were recruited to evaluate the statue, and within seconds sensed varieties of “intuitive repulsion” which informed them the statue was fake. However, the curators at the Getty spent fourteen months convinced the statue was real, somewhat do to compelling data, but mostly “because the Getty desperately wanted the statue to be real. It was a young museum, eager to build a world-class collection, the kouros was such an extraordinary find that its experts were blinded to their instincts (14)” I think this is something to be aware of — we all are all acquainted with situations in which we let our desire for an outcome or achievement cloud our intuition as we become fraught with over-thinking that is charged by emotional undercurrents. Instead of embracing my instincts in a display of confidence, I had recently become withdrawn under the burden of over-calculation. After advancing towards these conclusions I then asked myself, I feel confident using snap judgments in many areas of life, but was it appropriate for me to have these skills in the infancy of my medical training?      

Gladwell points out to readers that “it is striking, for instance, how many different professions and disciplines have a word to describe the particular gift of reading deeply into the narrowest slivers of experience. In basketball, the player who can take in and comprehend all that is happening around him or her is said to have ‘court sense.’ In the military, brilliant generals are said to possess ‘coup d’oeil’ – which, translated from the French, means ‘power of the glance:’ the ability to immediately see and make sense of the battlefield (44).” In the ER I was constantly being exposed to outstanding physicians with incredible clinical gestalt, medicine’s own “coup d’oeil,” if you will. And these outstanding physicians expected me to show them how my clinical gestalt was developing, essentially what kind of court sense does this student have? Initially I struggled with this, not because I wasn’t confident or had a lack of medical knowledge, but rather because I recognized and respected how humbling medicine, especially Emergency Medicine, is and I had to reconcile the relationship between confidence and humility regarding by own instincts. These were my first lessons as a future ER doctor. Learning to stand at the following intersection: both having confidence in “the ability of our unconscious to find patterns in situations and behavior based on very narrow slices of experience” and acknowledging Gladwells final conclusions: “It’s the kind of wisdom that someone acquires after a lifetime of learning and watching and doing. It’s judgment. And what Blink is — what all the stories and studies and arguments add up to — is an attempt to understand this magical and mysterious thing called judgment (260). You’ll never learn to trust your intuition if you don’t practice developing that trust within yourself and recognize the complex relationships and influences that affect our instincts. All I can ask for in moving ahead is to cultivate excellent judgment, which I finally feel to be less overwhelmingly “magical and mysterious,” but rather beautiful and powerful.  These reflections have allowed me to make a conscious effort to trust my intuition, acknowledge it and how it might be overshadowed or manipulated…and most importantly have confidence in my developing coup d’oeil. So far, it’s going pretty well. 

All rights reserved ©

Source:

Gladwell, Malcolm. Blink:The Power of Thinking Without Thinking. New York, NY: Back Bay Books/Little Brown and Company, 2005. Print.