Comments on: Let me sleep on it

By: Lance Knobel

Lance Knobel — Fri, 23 Mar 2007 16:20:40 +0000

Groopman discusses the use of both explicit and implicit algorithms in medical decision making. He’s skeptical. First, he thinks that’s not how doctors really think, even though idealized training may encourage that. Second, he thinks algorithms are fine for standard diagnoses, but fail in more complex circumstances.

By: Chris Bunch

Chris Bunch — Thu, 22 Mar 2007 23:06:19 +0000

Actually, medical decision-making is a variable amalgam of all three Minzberg styles, depending on the circumstances, the experience of the physician (together with, dare I say it, the level of innate common sense), and the evidence available to support the correctness/appropriateness of the decision being made.

A modern fallacy is that ‘one size fits all’, that all myocardial infarcts, strokes, pneumonias etc should be treated in exactly the same way. It *is* possible to generate sensible algorithms to aid the mechanistic management of common medical problems – and these *do* help to reduce the variability that characterizes inexperience – but they are can only guidelines to aid decision-making, not recipes to be slavishly followed.

As in so many arenas, the image of medical decision making portrayed by the media is but a mirror of its own propensity to trivialize and sensationalize. House MD is great fun, but not much more than that.

By: jaywalker

jaywalker — Thu, 22 Mar 2007 16:10:55 +0000

Henry Mintzberg summed up the three different decision-making styles as “thinking first” (anamnese,…), “seeing first” (pattern seeking, intuition, hunch, see Gary Klein) and “doing first” (trial+error).

While doctors are trained to follow the “thinking first” style, experience and time constraints lead them to a “seeing first” Blink process (terrible book, btw). “House, MD” celebrates in every episode the victory of his intuition over the methodical progress.

The military has long had to battle the dilemma of shielding the commanders from noise and danger (information overload) while still letting weak signals through (see van Creveld’s Command in War, too much isolation: WWI, Black Hawk Down). Unfortunately, the media celebrates “heroic” CEO leadership which is often ill-suited in our complex times.