Author Archives: kaylie

Medicine and Heuristics

Think back to a time when you found yourself in an Emergency Department, either as a patient or with family or friends. Depending on the city and the time of day, you most likely found yourself among many other patients waiting long hours in the waiting room with varying levels of maladies. After finally getting rushed back to a room you most likely were briefly assessed by an ED clinician and, if you were stable, treated and quickly sent home. If you have been several times, you know that almost always your assessment in the back of the emergency department is significantly shorter in duration than your wait in the waiting room. This is unfortunately the nature of an ER.

Ed clinicians work in an environment that demands speed and efficiency. They are required to see a large volume of patients as quickly as possible and in the case of a deteriorating patient, must make decisions almost instantaneously.  The ever increasing amount of patients in the waiting room only adds to necessity of efficiency. In such circumstances, the use of heuristics can be both valuable and deadly.

This entry in the Journal of Physician Assistant Education describes common heuristics utilized in the Emergency Department. The first heuristic mentioned is the Availability Heuristic. The Availability heuristic is based on the ease of which certain examples or events come to mind, in this case, in the , mind of the clinician. For example, during the winter months, clinicians experience an increase in the volume of patients experiencing flu like symptoms. After seeing so many each day, sometimes all in a row, it is understandable that the clinician becomes more likely to consider influenza as a diagnosis in their next patient with similar symptoms. This heuristic is helpful in the fact that it allows clinicians to quickly diagnose patients which eventually leads to them seeing more patients overall in a given amount of time. It can be harmful however, if a patient presenting with flu like symptoms during flu season, in fact is ill with some other disease. This heuristic would make the clinician more prone to misdiagnosing such a patient.

The next heuristic described in the article is the Representative heuristic. This heuristic occurs when a person is judged based on a characteristic or feature that is attributed to an entire group. For example, if a clinician believes young adults are more prone to anxiety then they may attribute the patient’s symptoms of chest pain and shortness of breath to anxiety because they fall into the group of “young adults.” While anxiety may be the cause of these symptoms in some patients it is not necessarily the cause in all “young adult” patients which would lead to a misdiagnosis.

The final topic mentioned is the Fundamental Attribution Error in which the failure or success of someone is attributed to who that person is as opposed to environmental factors that may be at play. In the world of emergency medicine, this would be evident when a patient’s chief complaint is considered to be their own fault. Of course, in some situations, a patient finds themselves in the emergency room as a result of their own actions and it is indeed their fault. However the Fundamental Attribution Error is at play when a patient, such as an obese patient, is complaining of symptoms that are automatically attributed to that patient’s weight. The journal article proceeds to give an example of this by saying that a “skinny” patient complaining of shortness of breath and leg pain will be evaluated differently than an obese patient complaining of the same things because the symptoms are automatically attributed to the obese patients weight. Obviously this could also lead to errors in diagnoses as well.

Overall, I agree with the article and believe it did a good job explaining the availability and representative heuristics in the context of an emergency department. I also believe it did a good job describing the Fundamental Attribution error however I am not so convinced by its example regarding the “skinny vs obese” patients. From a medical standpoint, it would be logical to evaluate a healthy patient complaining of a symptom uncommon for healthy patients, differently than an obese patient complaining of symptoms often linked to obesity. This is because each patient would have different risk factors and would therefore need to be considered in different contexts. Not all patients can be considered the same.

While heuristics may be beneficial in the emergency department, they can also be detrimental. It is clear that all clinicians should be aware of their tendencies towards these mental shortcuts so misdiagnoses that could result can be avoided. Working as a scribe in an emergency department, I have often found that I too utilize these heuristics when trying to determine the possible causes of a patient’s chief complaint. After seeing a certain pattern of symptoms and patient presentations lead to the same diagnosis over and over again, it is difficult to not draw that conclusion again when evaluating a similar patient.  In accordance with the availability heuristic, I often find myself considering the most severe diagnoses I have seen when being presented with patients with similar symptoms simply because these are the diagnoses I remember the best and most easily.  From my experience volunteering as a EMT, it is my suspicion that these heuristics extend to other providers in the field of medicine such a prehospital providers like EMTs and Paramedics. These providers must also make quick decisions based on very little information while treating patients.  Education in metacognition would most likely be beneficial to providers in almost all fields of medicine.

Invisibilia: Categories

                 From the moment of our very first breath, we become part of a category: Male, Female, infant, daughter, son, etc.  This seemingly simple concept of classifying our surroundings into manageable groups with shared characteristics affects us to a much greater extent than we are aware of on a daily basis. The use of categories in defining our surroundings is essential to our understanding of those surroundings and is inseparable from our experience. For example, one cannot describe or recognize objects without the use of their categorical knowledge. When we walk into a room, we know which item in the room can function as a seat, regardless of whether or not we have seen that specific seat before, because we utilize our knowledge of the category of seats to determine where we can sit. In a series conducted by NPR called Invisibilia, hosts explore new psychological research and strange phenomena. In this specific episode, episode 5 “The Power of Categories”, hosts of the series discuss categories and not only the human need for them, but the desire to be a part of them.

 The Power of Categories

               The episode begins by telling a story of a coffee shop in which customers are asked the simple question “cat or dog?” Though the question is short and seemingly insignificant, it has had interesting effects on the clientele. Patrons within the shop gladly declare themselves as one category or the other and then attribute an entire world of qualities to each category. They say things like “dog people are chatty” and “cat people like to stay at home.”  The significance of being a “cat person” or “dog person” exists because people have contributed characteristics to these categories that help them understand the world and make judgement based on their understanding.  This demonstrates that categories are necessary but even further; it shows that categories are desired. The patrons who assign themselves to a category, do so gladly, and the shop reports that there is an increase in the number of tips it receives because of it.

The next part of the series further stresses the importance of categories by presenting a woman named Paige who states has felt throughout her life that she as “flipped” , sometimes multiple times a day, between perceiving the world as a man and perceiving the world as a woman.  An interview with Paige within the series reveals her struggle. She states throughout her life, the issue was not that she was a man or that she was women depending on the time but that she was “in between categories.” In the end of this segment, a follow up interview with Paige a year later reveals that she has become happier simply because she has found a category to belong to, regardless of whether it is a category commonly accepted by society.

The next segment explores the desire of Iggy Ignatious to return to India. Because of family, he is unable to return to India, so he decides to build a retirement community in Florida called “Shantiniketan.” This community is complete with all the characteristics of the category Iggy attributes to his home and is extremely popular among Indian immigrants. Iggy stresses that no one is excluded from the community; however all of his residents are Indian immigrants. The popularity a community of this time is attributed to an individual’s desires to live in a community “just like them.” Iggy states it is hard to live as an outsider and after reaching an old age, his and many of his other residents wish to experience the relief of being surrounded by a community to which they belong.  Iggy’s idea that this set up is ideal at the end of a person’s life is supported by research done by Jeff Greenberg at the University of Arizona. Greenberg studies human behavior “when death is on the mind.” He states in that state, people like people in their own group, that is “Italians like Italians, Christians like Christians.”  He speculates that this happens because death haunts us and in an effort to fend it off we dive into a category we belong to in order to obtain the illusion that we are enduringly significant. Though many people reading may not have considered these ideas, I feel that no one can argue that there is comfort in “being among your own.” There is comfort in being a part of a group or category, in which you know the rules and characteristics and feel innately a part of.

The final segment presents the listeners with a story. The story uses the term “vast majority” to describe a category of people. Those who read the story and experience an uplifted mood are said to experience it because they believe themselves to be a part of this “vast majority” and therefore, are comforted in being a part of a category, in belonging. Those who listen to the story and are without a reaction are said to not belong to the vast majority so they do not experience an uplifting mood. The series presents several people who read the story and had either positive or indifferent reactions.

Throughout the series the concepts of categories and their importance in our lives are accurately portrayed. However, the series extends the importance of categories to a sense of belonging and a sense of home, instead of just discussing them in the sense of our interpretation of the world. Though I had not thought of categories in that way before, from my experience thus far these inferences make sense. The need to belong to a category or a group is evident in everyday life. It is clearly demonstrated in the way people describe themselves, in the clothes they wear, and in the way they speak.  More research in this area would be useful in determining whether people at the end of their lives are more comforted by the sense of belonging than they are by being surrounded by other people “in their category.” Furthermore, investigation as to whether this sense of belonging can be obtain even when surrounded by people “of other categories” is necessary.

Brain Games

Intuition has been referred to as many different things. It has been known as our “gut feeling”, our instincts, our six sense. It occurs so quickly it is often also referred to as a reflex.  Fast, subconscious processing provides us with information that simply “pops into our heads” and gives us the answers we need to navigate through our lives.  Intuition can be affected by our previous experiences.  For example, people working in specific professions often develop an insight or “gut feeling” which helps them perform more proficiently than those without experience.

National Geographic has developed as series called Brain Games that is dedicated towards examining various cognitive processes through a series of interactive games. In their episode called “Intuition”, a series of tasks are utilized to present the various types of intuition. The episode begins with flashing a number of objects, fish in this case, on the screen. The fish are not on the screen long enough to count, however, the viewer instinctively knows how many fish were presented on the screen.  This is an example of intuition. The viewer is able to intuitively guess the number with surprising accuracy, even though they were unable to count the individual objects. The episode then goes on to present another game demonstrating the powers of intuition. In the next game, three words are placed on the screen. The viewer must think of a word that can match all three of the presented words. They are only given three seconds to do so however, therefore they do not have the time to sit and think about the task.  Volunteers on the show were able to rely on their intuition to quickly process the three words on the screen and come up with a word that matched them all.  The volunteers stated over and over that the words would simply “pop” into their minds.  This example of intuition demonstrates the quick, subconscious processing required to complete this task within a three second time restraint. The episode further goes on to examine expert intuition and how it is developed through years of experience.

I believe this is a very informative and reliable series that effectively demonstrates various cognitive processes. There are some experts mentioned throughout the episodes, however, research studies and previous experiments to support the findings of the show would improve it greatly.

There seems to be relatively little research on the role of intuition in various situations. Further research on the development of expert intuition would be beneficial because those findings could be applied to training programs for new members in certain professions in order to facilitate the development of expert intuition.

The role of the Hypothalamus in location recognition

The ability to recognize objects, our location, and faces is a skill we very often take for granted simply because for most of us, it is effortless. Without struggle we can walk into a room and identify the components within it because this information is processed without conscious effort. One does not have to focus on and think about which object in the room is a chair or a desk or a person.  The information is simply just there.  As the book mentions in chapter three, there are many suggestions for why this essential cognitive process occurs. Perhaps we break an object down into its features or compare it to set prototypes in our minds that are formed from previous experiences. Certainly evidence has accumulated through many experiences to show that some areas of the brain are highly specialized for specific cognitive tasks. For example, the role the fusiform gyrus plays in facial recognition. In an interview conducted by RadioLab with a woman named Sharon Roseman, the idea that a specific area in the brain is specialized for specific recognition tasks is further explored.

RadioLab: You Are Here

The interview begins with Mrs. Roseman explaining a phenomenon she has had to deal with most of her life. She states at the age of 5 years old, while playing a game, she suddenly was unable to recognize her surroundings. She describes it as the entire world “shifting 90 degrees.” She states this inability to maintain an idea of her surroundings caused her to struggle with several daily life tasks like walking to a store or going to a friend’s house. She was able to identify objects such as houses, streets, cars, etc. however she was unable to identify where she was located. In her recount of this occurring at the age of 5, she states she was able to identify her mother but she was confused why her mother was there because she did not recognize the house as her own.

Later on in life, after numerous normal medical tests, Mrs. Roseman is able to make contact with Dr. Guiseppe Iaria.  He connects her to another woman, also named Sharon, who experiences similar deficits in recognition. Together they explain that they have learned to offset their afflictions through the use of map books and GPS navigation devices. They are eventually diagnosed with developmental topographic disorientation, or DTD, a disorder that is caused by an underdeveloped or absent hypothalamus.

This episode of RadioLab then further explains that according to very recent research, it is apparent that a region in the hypothalamus is responsible for creating a “map” of our surroundings in our minds. It explains that there are different types of cells that may be responsible for making one aware when he or she is near a wall or facing a specific direction. It makes sense to conclude that one with a defective hypothalamus would then have difficulty recognizing their surroundings.

Normal Hypothalamus depicted

While I believe that this is a credible and well trusted source, this episode of RadioLab raises more questions.  The hypothalamus has been shown to play a role in many cognitive and physiological functions, so would one with a malfunctioning hypothalamus be likely show other deficits as well? Or in the case of DTD, does only a specific region of the hypothalamus go underdeveloped?  Further research into the cognitive processes related to recognition and the specialized brain regions associated with them is no doubt necessary.