In the practice of medicine, where so much depends on one’s actions, there is, unsurprisingly, an ongoing discussion about what types of practices lead to the best outcomes, and in 2003 the Joint Commission approved the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery79. The protocol referred to as “time out” is a set of procedures that are aimed at getting doctors to relinquish their “automatic mode” of action, and to think before any surgery occurs in order to avoid errors such as amputating the wrong foot or performing an operation on the wrong patient. The protocol, among other things, requires the surgeon to mark on the patient’s skin where the incision is to occur, to certify that the correct patient is on the operating table, and to take a moment to have the entire surgical team agree on the procedure. In trauma, where time is of the essence and when it is obvious where the site of injury is, marking is not required, yet the team will still take a moment—a time-out—and make sure everyone is in agreement about what is to occur. Thus, according to the Joint Commission, even in high time-pressure situations, all things considered, thinking is beneficial. Acting without thought, they believe, leads to too many mistakes.80
According to the psychologist Fernand Gobet, however, “one of the hallmarks of expertise is the speed and ease with which experts can recognize the key features of a situation, a phenomenon often called “‘intuition.’” And to illustrate, he tells us that “a radiologist can diagnose a disease nearly instantaneously, and a chess grandmaster can literally ‘see’ the good move straight away,” adding that “with routine problems, the decision will be correct most of the time” (Gobet & Chassy, 2009: p. 151-2). I agree that experts often can do this, and that with routine problems, the decision may very well be correct most of the time. However, on my view, truly amazing expert actions typically are not a matter of seeing what to do straight away and doing it without any mediating thought. They involve at least thought in action, and in some cases, as the success of “time out” seems to indicate, they involve some prior thought, even when they might appear to need to be performed without delay. I shall devote Chapter 11 to chess (in which we’ll see that Gobet’s views are actually not so far from mine); however, let me now investigate performance in radiology a bit further. Though not typically a high time-pressure practice, it nonetheless has seemed to some that radiologists’ actions in making a diagnosis are made instantly.
Practice, no doubt, enables radiologists to make quick judgments, and to recognize some key features of the relevant situations nearly instantaneously. However, again, as with the surgeon or expert nurse, deliberately slowing down the thinking process appears beneficial. The physician Jerome Groopman illustrates this well in his book How Doctors Think, explaining how the radiologist Dennis Orwig proceeds in a systematic manner and avoids making errors by “slowing his perception and analysis” (2007: p. 182). When he proceeds in this way, Orwig says:
My brain is forced to work in a …stepwise way. It is easier—certainly quicker—to simply look at the pneumonia in the right lower lobe of the lung…and not take the time to detail all of the other information. But this protects me….I am literally reading hundreds of x-rays, day after day, on different patients….I have to keep reminding myself to be systematic. The more experience you have, the more seasoned you are, the greater the temptation to rely on gestalt. (p. 185)
However, those who promote the just-do-it principle often claim that relying on gestalt is exactly what an expert must do.81
Gobet, though he thinks intuition is important, does not endorse unqualified intuition. Rather, as he has made clear in his work on chess, he thinks that intuition and deliberation must work hand-in-hand. Moreover, as he suggests above, it is only with routine problems that intuitive decisions will generally be correct. But what is meant by a “routine problem”? Certainly if we mean by “routine problems” those that generally can be correctly solved without thought, then, of course, routine problems generally can be correctly solved without thought. But if “routine” means the general type of problem experts encounter on a daily basis, it is not clear, at least as Orwig seems to see it, that such problems should be solved without thought. Perhaps most of the films a radiologist looks at could be correctly evaluated without much deliberate thought; however, it is better to slow down and think so as to not miss a crucial feature.
The practice of dermatology is similar to radiology in this respect; that is, although fast and intuitive judgments would likely be right in simple cases, it seems that dermatologists deliberately slow down in performing full-body scans so as to not miss key but subtle indicators of disease. Or at least, this is what I have been able to gather. Dermatology seems so effortless: with apparent nonchalance, dermatologists observe a patient’s skin with often no outward signs of thoughtful consideration. However, the nonchalance may be illusory. As Dr. Elizabeth Hale explained rather incredulously, when I asked her about whether she needs to think about what she is doing, or if the problems just pop out to her, “it’s definitely conscious”; she went on to tell me that she not only thinks about a patient’s various moles, but also consciously follows a set order of steps to make sure that she does not miss anything (personal communication). Her sister Dr. Julie Karen, also a dermatologist, was in agreement, adding that it is never easy. Again, as I mentioned in the introduction, such anecdotal reports are certainly not conclusive evidence for the think-to-win principle. However, I take them to illustrate the view that I am arguing for and perhaps even append a question mark to the just-do-it principle.
Radiologists and dermatologists—or some, at least—slow down to improve their judgments. Yet could it be that in certain situations any amount of “time-out” before action would be disastrous? If the choice is either do something immediately and possibly save a life, or wait a second to think and certainly lose one, then, all other things being equal, one needs to act. The time-out protocol does not admit exceptions, though in certain situations the steps may be carried out less formally and in action. But might there be other actions which cannot allow for any amount of time-out?