Book Review
In the Blink of an Eye
By Carl Patow, M.D., M.P.H.
Malcolm Gladwell explores the power of first impressions.
A physician opens the door to the exam room and looks around, briefly catching essential details. She sees a thin man in his late 20s, with long blond hair that’s somewhat disheveled sitting in the chair. A few days’ growth of beard partially hides several scars on his chin. His plaid shirt is tucked into his oil-stained, gray pants. His heavy black shoes are wet and dirty. He has a wrinkled brown shopping bag in his left hand, but the contents are not visible. And as he slowly lifts his head, he looks at the physician through tired, deeply recessed eyes. She is sure he is seeking narcotics.
Or maybe not.
This fictional encounter illustrates the central thesis of Malcolm Gladwell’s newest book, Blink: The Power of Thinking without Thinking. The book celebrates the power of the glance, the unconscious act of making judgments based on a few seconds of observation. It’s a process called “thin-slicing.” Although we like to believe that we make judgments based on careful, rational thought, first impressions are often the primary means by which we make decisions. Gladwell argues that decisions made quickly can be as good as those made more deliberately.
Thin-slicing refers to the ability of our subconscious to find patterns in situations and behavior based on very narrow slices of experience. In medical settings, thin-slicing is practiced both by physicians and by patients. Gladwell cites research by University of Toronto Professor Wendy Levinson, M.D., comparing patients’ impressions of two groups of surgeons: those who had been sued at least twice and those who had never been sued. She studied the conversations between
patients and these physicians and found differences in how the physicians talked with their patients. Physicians who had not been sued were more likely to spend slightly more time with patients. They were better at providing short “orienting” comments to patients to help them feel comfortable during the history and examination. They engaged in active listening, encouraging patients to provide additional details about their condition.
In a related study by Tufts University social psychologist Nalini Ambady, Ph.D., the taped speech of physicians who had been sued and had not been sued was electronically filtered to remove any recognizable words. Judges listened to only 10 seconds of content-free speech from the two groups of physicians and rated the tone of voice on characteristics such as warmth, hostility, dominance, and anxiousness. Based on these ratings, Ambady was able to accurately predict which surgeons had been sued. The implication is that the first few seconds of conversation in the exam room may predict the success of the entire physician-patient relationship. Gladwell suggests that patients should thin-slice their visit with a new physician and pay attention to their feelings during those first few minutes, as they may provide clues to the eventual success of the relationship.
Gladwell contends that thin-slicing is a necessary skill for human survival but says it is fallible. The personal experiences, intuition, and quick responses on which thin-slicing relies can sometimes prove less effective than simple logical principles. Gladwell discusses the research of Lee Goldman, M.D., a cardiologist who is now chief of medicine at the University of California, San Francisco, who created a decision tree that recommends treatment options for patients who present with chest pain. Goldman’s criteria are simple and based on ECG evidence and three risk factors: whether the pain felt by the patient is unstable angina; whether there is fluid in the patient’s lungs; and whether the patient’s systolic blood pressure is below 100.
When Goldman originally proposed the idea of using his decision-making system, there was little interest by other investigators in applying his criteria clinically. The reason, they said, was because Goldman seemed to discount many factors that experienced physicians intuitively believed to be important risk factors for heart disease. But after testing the criteria in the emergency room at Cook County Hospital in Chicago, Goldman proved that the criteria were superior to physicians’ clinical impressions in distinguishing which patients were and were not presenting with myocardial infarction. In this case, less turned out to be more, as the additional information used by physicians in making diagnoses turned out to be misleading. Although the Goldman criteria are featured in the book, they are not routinely used in clinical practice. In the litigious environment of contemporary clinical medicine, clinical studies are routinely relied upon to confirm diagnoses. Gladwell simply uses the criteria to demonstrate that too much information can be misleading when making decisions.
Gladwell concludes that truly successful decision-making relies on a “balance between deliberate and instinctive thinking.” Gladwell also recognizes that overloading the decision-maker with information does not necessarily make the decision easier or better.
A disturbing aspect of thin-slicing is that it can reveal unconscious attitudes that Gladwell writes may be “incompatible with our stated conscious values.” Subtle environmental cues can affect behavior and judgment. For example, exposure to selected words prior to answering a series of psychological test questions, a process known as “priming,” can unexpectedly influence the results. For example, exposing test subjects to the words “white” and “good” before taking a test on racial attitudes can shift responses of subjects toward equating pictures of white people with positive character traits.
Ignoring prevalent-but-subtle influences can be difficult. Simply stating a belief that patients ought to be treated equally may not actually lead you to treat them equally. To illustrate this point, Gladwell shares the research of Yale economist and legal scholar Ian Ayers, J.D., Ph.D., who studied the behaviors of car salesmen in Chicago toward customers of different races and genders. Car salesmen who made instantaneous judgments about potential customers based on their race and gender potentially lost sales by inaccurately estimating a person’s buying power. For example, when dealing with a female or a black customer, salesmen tended to quote a higher sales price for the vehicle, a strategy that alienated people who otherwise might have purchased a car. Gladwell conjectures that the salesmen were not bigots, but more likely were making unconscious assumptions about the buying habits of these groups of customers, a practice that cost them sales.
As the book’s jacket states, “Blink is a book about how we think without thinking, about choices that seem to be made in an instant—in the blink of an eye—that actually aren’t as simple as they seem.” The author gathers the evidence to support the claim that instantaneous decisions and actions are prevalent, important, and underrated. The involvement of the neural pathway in impulsive thinking is suggested but not elucidated. Gladwell suggests that improved decision-making can result from training these pathways, but he doesn’t provide a blueprint for doing so. In part, these shortcomings of the book reveal the shortcomings in our knowledge of the brain’s function and the cognitive wall behind which many decisions are made.
Physicians and other professionals rely on intuition to make rapid decisions in time-restricted environments. This book may help them better understand how they make decisions and see the limitations and consequences of thin-slicing. For those reasons alone, it’s well worth reading. MM
Carl Patow is executive director of HealthPartners’ Institute for Medical Education.