Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

How to Improve Clinician-Patient Connections, Part 4

"I tend to think I'm above average in singing, but my family isn’t shy in telling me that I’m unskilled and unaware."


My “fast” thoughts about a patient may not truly represent their experience. “Slow” thinking may give a more accurate picture.  

Connecting with Patients | February 9, 2022 | 2 min read

By Christine Ko, MD, Yale University

For anyone interested in thinking about metacognition, I highly recommend Dr. Daniel Kahneman’s book, “Thinking, Fast and Slow,” and Michael Lewis’ book, “The Undoing Project.” 



Kahneman breaks thinking down into two types, termed System 1 and System 2. No one part of the brain houses neurons related to either of these systems; they’re semantic markers of thinking. System 1 is fast thinking: gut reactions, instinct, bias, recognizing patterns, and also expert thinking. System 2 is slow thinking: analyzing and using logic. Neither system is better than the other and they can be synergistic.


MetaCOGNITION in doctoring 

The rigorous training of med school and residency is geared toward creating System 1 thinking, like patterns of disease presentation.There’s also System 2 thinking when you analyze a treatment plan prior to making decisions. When I see a rash and know at once what it is, that’s System 1. Similarly, when I see a rash and don’t know what it is, my analysis of the data available to me is System 2.


MetaPERCEPTION in doctoring 

Thoughtful care of patients takes not only careful thinking but also rigorous listening and observation. An observing habit can be developed through “fast seeing,” analogous to System 1, and “slow seeing,” analogous to System 2. The same is true for a listening habit. In other words, when I think I perceive an angry patient who’s only answering with monosyllables, I should step back. What am I truly seeing and hearing, and what emotional overlay am I myself creating? Is my interpretation correct? Perhaps instead, the patient is fearful, upset, and uncomfortable speaking their feelings aloud. Metaperception is just as important as metacognition in connecting with patients.


The Dunning-Kruger effect 

Drs. Dunning and Kruger elegantly showed in their experiments that humans are usually unskilled and unaware, particularly when their skills are on the lower end of average. Basically, in order to know how well you do something, you need to have enough mastery to have an idea of what it takes to be outstanding. Those who are unskilled have an incomplete sense of what true expertise looks like and have an inflated sense of their own competence.


The Dunning-Kruger effect applies to me! I tend to think I’m above average in singing, but my family isn’t shy in telling me that I’m unskilled and unaware lol. The Dunning-Kruger effect is critical when examining metacognition and metaperception, because most of us, myself included, believe we’re above average in our ability to think and perceive. I need to accept that my thinking and perceptions might be wrong. I can improve my ability to connect with patients by working to improve habits of listening and observing.


For more info on these topics, check out my book and my previous CLOSLER pieces:

My book: “How to Improve Patient-Clinician Connections”

CLOSLER pieces:

Cognitive Psychology and Patient-Clinician Connections, Part 1

Part 2

Part 3







This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.