Automatic responses from previous experiences and memory

In seeking knowledge, the first step is silence, the second listening, the third remembering, the fourth practicing, and the fifth is teaching others.
- Ibn Gabirol

When we learn a skill such as driving a car, we initially have to practice each component of turning on the engine, releasing the parking brake, putting the car in gear, steering as we step on the gas pedal, scanning for road clearance and hazards, braking, and so on. As we become proficient in all of these maneuvers, they become habitual and we can do them with little thought. Our automatic responses may be so good that we could be lost in thoughts and suddenly realize that we have driven some distance and cannot recall any conscious adjusting of the steering, braking, or other controls of the car.

The same processes of automating responses occur as we learn other skills, such as clinical medical and nursing interventions. Going through a medical history and examination is initially a complex process, involving myriads of details of information and procedures. The more experienced we are with these, the more they become automatic.

Clinicians are able to draw from their mental databases of knowledge in order to respond to situations rapidly and efficiently, often with little thought. Surgical bleeding occurs, and the surgeon instantly reaches for a clamp and stops it. The patient gags or retches, and the nurses’ hand is instantly reaching for the nearest handy towel or basin.

This is a basic level of intuition, in the sense of recognizing a problem and knowing what to do without having to consciously analyze the details and respond through conscious, logical deductions in order to respond to a situation.

Cognitive pattern recognition

Let us train our minds to desire what the situation demands.
Seneca

A patient presents with depression, gravelly voice, and thick hair and the doctor, who hasn’t seen a case of hypothyroidism this severe since reading his medical school textbooks many years earlier, instantly recognizes that this is a case of hypothyroidism.

A surgeon asked me to see a 23 year-old patient after his appendectomy because he was depressed. His parents reported he had always been something of a loner. As I spoke with him, I felt uncomfortable because his eyes would not meet mine. The diagnosis of Asperger’s syndrome came to mind, from having seen children 5 to 10 years old with such presentations – particularly the avoidance of gaze. Further questioning confirmed this to be a very likely diagnosis. I hesitated before sharing this impression, because it suggests an incurable problem, with the patient likely to remain autistic and distant from everyone. The parents, however, were extremely grateful because at last they understood their son’s problems and could plan how to deal with them.

Clinical pattern recognition may be more subtle. Clinical sensitivity often leads doctors, nurses, and other caregivers to recognize when something is going wrong or going well. Postoperative nurses will often report a sense of a patient “not being right,” although objective signs and symptoms are within normal limits. Often, these sorts of intuitive awarenesses prove correct, and an internal bleed or other problem develops soon after the nurse’s intuitive “alarm bells” start to ring. At other times, the nurse will sense that all is well, and the patient will have an uneventful postoperative course (King and Clark 2002).