I will admit to being one of those people who went into the last election believing Justin Trudeau was “just not ready”. Too young. Too cocky. Too good looking. Just too perfect. Too dissimilar, I believed, from his famous father who I greatly admired and supported in the past. In fact, over forty years ago, I was quite an ardent supported of Pierre Trudeau. My brother and I were Young Liberals who campaigned actively for his election, and even had the opportunity to meet him briefly at a party event. He was young, intellectual, worldly, unabashedly unconventional, and professed a fresh vision of an open and inclusive “Just Society” that was, frankly, inspirational to idealistic (and probably naive) young people who were eager for change after the long line of staid and decidedly uninspiring conservative leaders who preceded him.

I was explaining all this to one of my sons a couple of weeks before the election when he asked, rather innocently, how was Justin so different from his father? What’s different now than then? Well, I began to explain wisely (and rather defensively), the world’s a vastly different place, much has changed…blah, blah, blah. No doubt true, but as I considered all this further I came to realize that what’s really changed, what really underlies my doubts about young Justin, is me. My own attitudes and perspectives have changed rather profoundly, altering both my comfort with status quo and willingness to embrace uncertainty. All this also brought to mind a piece of advice I came across in a leadership article recently:

“You need to know what you know, what you don’t know, and when you might not know”

All this speaks to the concept of Metacognition. This term, easily dismissed by the righteously self-assured as edu-babble, refers to “cognition beyond cognition” or, more simply put, “thinking about thinking”. The essential concept is that helping students develop self-awareness about their own learning strengths and weaknesses will make them better learners, both now and through their careers. Brings to mind the adage “give a man a fish, you feed him today – teach him to fish, he feeds himself”.

Contemporary interest in metacognition is credited to developmental psychologist John Flavell who published a number of articles in the 1970s which have triggered considerable educational theory. The concept and practice, however, is ancient and is perhaps best exemplified by Socrates who famously challenged his students with probing questions, forcing them to examine and question their own thinking process rather than simply their ability to relate factual information. Many believe that the single quality that differentiates the accomplished and comfortable learner from those who struggle, is the ability to understand how they learn and their ability to take charge of that process.

This is highly relevant to the teaching and learning of Medicine. Effective Physician teachers intuitively and instinctively foster metacognition whenever they challenge their students to explain their thinking or “approach” rather than simply produce a fact or single response to a problem. The emphasis on reflection and portfolio development in medical school are attempts to foster this awareness in our novice learners. Accomplished, highly regarded diagnosticians and scientists are not simply sources of accumulated knowledge. They are expert problem solvers who are able to focus their thinking and creativity on fresh challenges. In fact, they thrive on such challenges and are bored by repetitive application of “conventional” wisdom.

In addition to recognizing and refining our own learning processes, metacognition forces us to confront the fact that we may harbour unintentional cognitive bias. Even a casual search of the term uncovers numerous examples of such latent biases that sound disturbingly relevant to medical decision-making, and probably affected my election decision dilemma. Consider the following:

Anchoring is the tendency to rely too heavily on one trait or piece of information when making decisions. Consider our reliance on demographics, specific risk factors, clinical findings or diagnostic test results that we favour or are more adept at interpreting.

Availability cascade refers to the tendency to rely on events more “available” in our memory, which can be influenced by how emotionally charged they may be. This seems relevant to a physicians tendency to be strongly influenced by recent, adverse outcomes.

Choice-supportive bias is the all-too-human tendency to remember one’s choices as better than they actually were. Enough said.

Confirmation bias is the tendency to search for or interpret information in a way that confirms one’s preconceptions. In medical terms, favouring data that supports our hypothesis and discounting information that doesn’t.

Conservatism is resisting new evidence. The Semmelweis Reflex has come to be associated with rejection of new ideas simply because they’re new. It’s named for Ignaz Simmelweis, an Austrian physician who, in 1846, postulated and observed that maternal and infant mortality was much higher on wards where the physicians moved between autopsies and wards without washing their hands. Semmelweis met with great resistance from his colleagues. In doing so, those colleagues were demonstrating the Status quo bias, which is the tendency to want things to stay the same, to the extent that it prevents appreciation of new ideas or approaches.

Framing effect refers to our tendency to draw different conclusions from the same information, depending on how that information is presented. Any of us who have learned how to deliver critical feedback in conjunction with positive commentary knows what this is about. A related term is selective perception, the tendency for expectations to influence perception – we see what we wish to see.

Negativity effect is the tendency to unevenly evaluate the behaviour of a person one dislikes. This leads us to attribute their positive behaviours to the environment and their negative behaviours to the person’s inherent nature. Our political leaders, most recently Mr. Harper, are undoubtedly victims of this phenomenon.

Optimism bias is the tendency to be overly optimistic with respect to outcomes that we see as favourable or intrinsically pleasing. No doubt Mr. Trudeau benefited from this during the recent election. In the medical context, this might influence how we express interview questions, hoping to develop a picture of favourable outcome to therapies we’ve provided.

Reactance is the urge to do the opposite of what someone wants you to do because you perceive constraint to your freedom of choice, or sense of control. This speaks to less noble aspects of our nature, and is linked to reactive devaluation in which we devalue proposals or suggestions only because they originate from someone we do not value or view as an adversary.

All these concepts relate to limitations fundamental to our human nature and are relevant whether we’re doing the weekly grocery shopping, voting in elections, or making medical decisions. It also seems clear that nothing about the concept of Metacognition is new, in either Medicine or in everyday human affairs. Recognizing it as a valid learning process, and acknowledging the various ways in which our own engagement of new ideas and decision making can be unintentionally influenced is, I believe, of considerable value.

Trudeau-blog2By the way, I’m still not sure about young Justin, but I voted Liberal.


Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education