As fundamentally social primates living in and dependent on exceptionally large and heterogeneous groups, other humans are among the most important features of the environment for humans. For humans, having the capacity to infer the intentions, goals, and feelings of others is essential for the Darwinian goals of survival and reproduction. In fact, the networked nervous system is the default state of the human nervous system. We come into the world innately attuned to the faces and voices of other humans. Building on these foundations we go on to develop a theory of mind (mentalizing); readily and effortlessly ascribing intentions, feelings, and goals to the action of others. Thoughts such as what are they thinking, what are they feeling, what do their actions mean, how do they feel about me, are on our mind, lurking nearby, and probably always attended to by the subconscious.
Typical human communication occurs over multiple interrelated channels, with language being the proverbial tip of the iceberg. Partially due to the limits inherent in language and the limits of introspection, our words represent only a small fragment of what we know or feel. Prosody, hand gestures, eye contact, facial expressions, and postures all carry salient information. Human communication is inundated with nonverbal signals interspersed with language. As context demands, we consciously and subconsciously utilize this rich source of data complementarily or independently to infer mental and bodily states of the communicator. Is the other person engaged or distracted, anxious, or inattentive? What does that frown mean? Why are they not making eye contact? Is the other person trustworthy, do they intend to deceive, are they feigning interest?
Although mentalizing is a capacity that all humans have developed, the skill can be improved and specialized with practice. One such specialization occurs over the course of medical apprenticeship and through patient encounters. Physicians not only hone their theory of mind but also develop a specialized ability to infer underlying disease states by conducting physical exams. Signals from the autonomic nervous system such as dilated pupils, pale conjunctiva, moist skin, erect hair, fast heart rate, and diminished bowel sounds can yield contextual diagnostic cues when combined with the various channels of human communication. This ability to integrate and then infer disease states is especially important for the “foggy road” that is the emergency department, where salient clues can be latent, typically reliable cues can be misleading, and the costs of mistakes can be catastrophic.
Nearly 500 years ago, the poet John Donne famously wrote, “No man is an island entire of itself; every man is a piece of the continent, a part of the main.” This appears to be a fundamental truth of our species. Human nervous systems depend on other nervous systems for development and maintenance, and consequently, the ability to “know others” is an evolved and developed feature of our nervous system. A human brain belongs among other human brains. Through experience and training, physicians not only hone their skills of mentalizing but also expand on this ability by being able to infer disease states. This specialized ability to mentalize in tandem with its complements of metacognition and interoception should be core competencies for all physicians but especially for emergency physicians. However, the “realities” of the emergency department leads to a mismatched environment, which in turn leads to predictable errors of metacognition and interoception, but additionally the systemic pressures of emergency care have shifted to devalue the development of a specialized theory of mind (next essay).