The problem of thinking

We have so far reviewed different facets of unconscious or intuitive clinical judgment. We will now look at the place of conscious or analytical thinking in decision-making. Unlike the simple and fairly easy intuitive process, analytical thinking is both complex and difficult. Indeed in his book Think Better: An Innovator’s Guide to Productive Thinking, Tim Hurson portrays thinking as ‘hard work‘, and to illustrate this, he broke down thinking into its several challenging components:

Observing

Wondering

Imagining

Inquiring

Interpreting

Evaluating

Judging

Identifying

Supposing

Composing

Comparing

Analysing

Calculating

Thinking about thinking (metacognition)

Hurson went on to define thinking as a two phased creative process which starts with the non-judgmental generation of ideas – what he calls reproductive thinking – and this is followed by the process of choosing the right solution – what he terms productive thinking. He emphasised that as many ideas as possible must be generated if thinking is to be a successful creative process. And because the best ideas tend to emerge later in the process (after all the obvious options have been exhausted), the person thinking has to persevere for the best outcome to emerge. Therefore, as ubiquitous as it may appear to be, thinking does not come naturally. This is why Hurson described it as a skill which, like all other skills, has to be ‘taught and developed and nurtured regardless of IQ’. 

In discussing analytical thinking, two particular types are relevant to healthcare, and these are critical thinking and statistical thinking. We will explore each of these in further detail.

Critical thinking

Sharples and colleagues, in their paper titled Critical Thinking in Healthcare and Education, described critical thinking as ‘the ability to think clearly and rationally about what to do or what to believe‘, and they portrayed it as a skill that ‘is essential for the practice of medicine’. Asserting that ‘it is important for clinicians and patients to learn to think critically’,  they argued that ‘the teaching and learning of these skills should be considered explicitly’. On their part, Croskerry and Nimmo, in a paper titled Better clinical decision making and reducing diagnostic error, describe six stages in the evolution of critical thinking; at the bottom is the unreflective thinker who doesn’t self-monitor his or her thoughts, and whose thinking is undermined by prejudices and misconceptions. The hierarchy then progresses through the stages of the challenged, the beginning, the practicing, and the advanced critical thinker. At the top of the pyramid is the accomplished thinker who ‘systematically takes charge of thinking and strives for improvement‘, and who is able to assess thinking for such features as its clarity, accuracy, precision, relevance, and logic. The authors further characterised the accomplished thinker as having a ‘high degree of intellectual humility, integrity, perseverance, courage, empathy, autonomy, responsibility and fair-mindedness‘. 

Fat Thinker, Shanghai Sculpture Space. William on Flickr. https://www.flickr.com/photos/heyitschili/4840167003

Statistical thinking

Statistical thinking is perhaps the most challenging form of thinking for most people, and it is a cause of serious errors in the clinical judgment of doctors. Writing on this theme in the book Better doctors, better patients, better decisions. Envisioning health care 2020, Wolfgang Gaissmaier and Gerd Gigerenzer particularly noted that doctors struggle to understand such fundamental statistical concepts as base ratesrisk, risk reduction, sensitivity, and specificity. They further argued quite strongly that the inability to think statistically is responsible for many healthcare errors such as the tendency to overestimate the benefits of screening interventions. Writing in the same book, Gigerenzer and Wegwarth illustrated the scale of ‘statistical illiteracy‘ when they cited studies which show that ‘most doctors have problems in understanding health statistics, including those from their own area of speciality‘. 

Sandsation ’09: The Thinker, Closeup. Sebastian Niedlich on Flickr. https://www.flickr.com/photos/42311564@N00/3699334558

Thinking is therefore quite a challenging task, but in the next blog post we will explore the 4 strategies that promise to make us all better thinkers.

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