Fluency and Its Illusions

Although we think of information overload as a contemporary phenomenon, throughout evolutionary history organisms have always had to grapple with a world brimming with noisy data. Ever present and life threatening features such as camouflaged prey, lurking predators, strategizing competitors, invasive species, weather changes, and insecure food supply have always been part of the challenges faced by living organisms. The evolutionary solution of learning patterns, balancing the tradeoffs between false positives and false negatives (next essay), and minimizing unknowns by constructing niches (upcoming essays) have always been a mandate for the evolutionary goals of differential survival and reproduction. 

However, in the context of limited cognitive resources and information overload, learnt patterns are also offloaded onto the parallel processors of the nervous system in a process called fluency. It is a measure of how easily, efficiently, and automatically a task is performed. Procedural skills such as walking, riding a bicycle, expertly playing an instrument are paradigmatic examples of fluent actions where attention can be diverted away from the action without sacrificing or even enhancing performance. Similarly, cognitive expertise also requires fluency. Observing the difference in reading in a literate adult versus a semi-literate child provides a clear example. Whereas the former chunks information at the level of words or group of words, the latter stumbles at the level of the letters and phonemes. In the literate adult, the processing of letters and phonemes is effortless and they devote attention to the meaning of the sentence, the paragraph, the chapter, and the entire book. Fluency enables the offloading and automatizing of “regular” tasks to not only enable us to be more efficient, but also allows them to focus their attention and direct learning to different, higher-level, and more abstract regularities in the environment. 

However, fluency is not only the property of the person but also environmental factors which can serve as facilitators or barriers. To extend the above analogy, reading in a scaffolded environment such as a well-lit and quiet room is obviously easier than performing the task in a dark or noisy room. Agents will actively seek out and construct niches that facilitate fluency.  This drive is so strong that the (mis)perception of fluency affects how we interpret information, evaluate uncertainty, assign confidence in our decisions, and appraise our performance. We feel more confident and have less uncertainty in decisions when we act more quickly. This is true, even if faster responses are not correlated with greater accuracy. As Daniel Kahneman states, “confidence is a feeling, which reflects the coherence of the information and the cognitive ease of processing.” The double whammy of efficient expertise in superficially or deceptively scaffolding environments can create situations where salient signals are unattended, attention is diverted, and decisions are impetuous. Furthermore, if these environments also do not have direct error feedback mechanisms relating actions to outcomes, it can create situations in which we (systemically and individually) feel as if we are performing well, correctly assessing risk, and making sound decisions, when in reality we are misreading the signals and underperforming.

In the volume-driven and ambiguous ecosystem of the Emergency Department, achieving fluency is not only a cognitive but also an economic necessity. Upon presentation to the Emergency Department, patients are quickly categorized based on a chief complaint, vital signs are taken, an Emergency Severity Index (ESI) is assigned, tests are reflexively ordered from those categorizations, and patients are funneled through the emergency department in an assembly line model. However, the emergency department is an error-feedback poor (next essay) system, where outcomes do not directly feedback to actions. The standardization of processes, the relative ease with which historical data is available in the electronic health record, and the top-down push to use generic clinical practice guidelines all create the illusion of fluency. This impairs metacognition and can obscure the risk inherent in the under-differentiated, culturally heterogeneous, complex socio-medical Emergency Department patients who come with low-base rate, atypically presenting, and seemingly discontinuous life-threatening diseases such as strokes, heart-attacks, pulmonary embolisms, aortic dissections, and sepsis that often elude surface level and reflexive categorizations. In the process, patients bear the impact of the iatrogenic curse of the false-positive and the morbidity and mortality of the false-negative (next essay).  

In a world that has always been awash in data, making “sense” of the world, offloading tasks, and reducing its complexity, has always been a necessity. Fluency is a necessity in life. Paraphrasing Alva Noe , without it, there would be no familiar pathways or known strategies for getting things done.  No routines would be in place and nothing could be taken for granted. Every action would require new thoughts, reflection, and deliberate action. Fluency in tandem with learning and niche construction are evolved, interdependent, and interrelated solutions to the problem of noisy data overload. It enables the perception-action loop to operate in the background without cognitive effort, freeing up those resources for learning new patterns and building new niches. However, the perception of fluency itself can lead to errors in cognition and metacognition, especially when ecological pressures impose the illusion of fluency. An ideal scaffolding environment will be one that not only augments decision making but also more accurately assess risk and uncertainty (upcoming essays).

1 thought on “Fluency and Its Illusions”

  1. […] practice of medicine is informationally open with vast areas of uncertainty. Disease categories and patient categorizations are relatively crude or are not fit for purpose, so unrecognized patient level variation and […]

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