A patient having his blood pressure taken by a...

A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)

( I have written this summary of my program using the less offensive nomenclature of System I and System II for the reptilian brain and for the new brain respectively).


When we tend the patient two systems are at work in the physician’s mind, System I and System II.

System I expresses the the hazardous attitudes that the aviation industry associates with near misses and errors or adverse events. The same hazardous attitudes are associated with medical near misses and errors.[i]

And System II by contrast is the only organ that can embrace the patient’s interest. We strive to maintain System II at all times but we drift gently from System II to System I, compromising the medical arts of active listening, self-questioning and doing the inconvenient (being thorough). Therefore we should practice to:

  • identify early signs of System I activity, counter it and return to System II agenda;
  • create a personal Irritability Barometer to identify System I’s activity;
  • Use an algorithm to monitor the the presence of System I activity;
  • diagnose the cause of the System I agenda;
  • use both the aviation-proven specific antidotes and some generic antidotes gleaned from the wisdom of the ages to counter System I;
  • create daily calisthenics to make self- monitoring a habit when tending patients.

[i] Daniel Kahneman, Nobel-prize winner, in his book,  ”Thinking, Fast and Slow”

describes the two systems:

  • System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control.
    • System 2 allocates attention to the effortful mental activities that demand it, including complex computations. The operations of System 2 are often associated with the subjective experience of agency, choice and concentration. One of the tasks of System 2 is to overcome the impulses of System 1. In other words, System 2 is in charge of our self-control.
    Kahneman lists 22 different characteristics of System 1, my comment appears in brackets after them:
    • Generates impressions, feelings, and inclinations; when endorsed by System 2 these become beliefs, attitudes, and intentions. ( Non rational)
    • operates automatically and quickly, with little or no effort and no sense of voluntary control.
    • Links a sense of cognitive ease to illusions of truth, pleasant feelings, and reduced vigilance. (Convenience of mental shotgun)
    • Infers and invents causes and intentions (Convenience of assumptions)
    • Neglects ambiguity and doubt (Convenience of defending one’s intellectual territory )
    • Is biased to believe and confirm (Convenience of defending one’s intellectual territory)
    • Focuses on existing evidence and ignores absent evidence (Convenience of ignoring challenging data)
    • Generates a limited set of basic assessments (Convenience)
    • Computes more than intended (Convenience of mental shotgun)
    • Sometimes substitutes an easier question for a difficult one (Convenience)


The list below contrasts the  activities and characteristics of the System I and System II.

The System I labels, likes and dislikes others and processes and is critical of others.
The System II is capable of being: non-judgmental of others and also can self-question and critique itself.

The System I is hasty, pressing, impulsive, and is restless, wishing to flee from the present activity.
The System II can postpone, deliberate, and is capable of being content about the present activity.

The System I favors the convenient.
While the System II can resolve to do the inconvenient.

The System I can be apathetic, complacent, take short-cuts, ambush the symptoms which are the least strenuous for us.
The System II can care and delve more into the history and examination. (Stellar work is always inconvenient)..

The System I is easily distracted and inattentive to the task at hand.
The System II is vigilant to the task at hand.

The System I promptly dismisses doubt, makes assumptions, lounges, and guesses.
While the System II gives doubt an honest hearing

The System I prioritizes one’s self-esteem before the needs of the patient.
The System II advocates the patient’s interests, not one’s own self-esteem. It has the humility to take it on the chin for the patient.

The System I is irritable, a salient characteristic of the reptile within.
While the System II is capable of Osler’s Imperturbability or Keats’ Negative Capability.

The System I hears but does not listen, interrupts frequently and talks over.
The System II is capable of active listening.

The System I reacts
The System II can self-reflect and self-monitor.

The System I is apt to naming as in diagnosing.
The System II is capable of un-naming, retracing and more tentative and open to other diagnoses.

The System I has emphatic expressions.
While the System II is calm and careful.


Wishing you aequanimitas during your upcoming consultations,


John Mary Meagher






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