Laterality, or left–right discrimination (LRD) is assumed to be innate or acquired early, but in one study, a majority of students scored less than 77% on an objective LRD test

Challenging  assumptions of  innateness –leave nothing unturned . Jason J Han & Neha Vapiwala. Medical Education, Mar 3 2019, https://doi.org/10.1111/medu.13824

It was once common in various academic fields to assume that individuals possess certain fundamental abilities or intuitions (e.g. the assumption of rationality in the fields of economics and social sciences).1 However, the past half-century has overseen a transition towards a different model of human cognition, one which acknowledges the human brain as complex machinery that is vulnerable to systematic errors.

The pioneers of this paradigm shift, Daniel Kahneman and Amos Tversky, attributed this to the co-existence of two processing mechanisms.2 They described the first, aptly named System 1, as the fast, automatic, intuitive, unconscious approach and the second (System 2) as the slower, more deliberate, analytical and conscious mode. The purpose of this categorisation was not to assign a hierarchy, but rather to acknowledge that both systems have their respective pros and cons depending on the task. System 1 is efficient but more error-prone. System 2 is more thorough but requires greater resources and quickly drains our working memory and attention, thereby making it too susceptible to error. In this issue of Medical Education, Gormley et al. juxtapose these two systems in the context of one of the most commonly performed mental tasks –our ability to discern laterality or left–right discrimination (LRD). This ability is particularly critical in medicine, as errors in LRD can lead to wrong diagnoses and interventions, and ultimately patient harm. The authors note that although LRD is often assumed to be innate or acquired during early stages of human development, in reality LRD is a complex neuropsychological process with which 17% of women and 9% of men have reported difficulty.3 Medical students are not exempt from this challenge. In one study, a majority of students scored  less than 77% on an objective LRD test.4 In the interviews conducted by Gormley et al., students who had difficulty with LRD disclosed feelings of inadequacy, which led to greater efforts to conceal this difficulty and even influenced their career trajectories by steering them away from certain specialties. Undoubtedly, these f indings have important implications for the medical education community, suggesting the need to overthrow assumptions that LRD is an  innate human skill and to raise the importance of laterality training in the curriculum.5

This study inspires the realisation that no tacit assumption of innateness or intuitiveness should go unchecked. What else are we assuming is easy, innate or intuitive? The distinction between what is presumably innate and what merits attention and practice is somewhat arbitrary. Observing that we teach correct anatomic spatial orientation, such as anterior from posterior, superior from inferior, Gormley et al. asked, why not also left from right? Extrapolating further, we could apply the same line of questioning to other competencies in medical education, such as our ability to recognise personal cognitive biases or develop ‘soft’ skills such as empathy and clarity of communication. There are undoubtedly circumstances in which we assume we effectively and expertly broke bad news, disclosed error or obtained informed consent, but in the eyes of the patient our performance was lacking. As such, we can all stand to gain important insights into our own abilities with a more conscious and thoughtful approach.6,7 1