I have long been a skeptic on the need for speed in all decision making. I remember the one-time European management hero Percy Barnevik declaring in Davos, “It’s better to be fast and wrong than slow and right.” Well, maybe once in a while.
I’m glad that my predisposition to reflection is echoed in the fascinating How Doctors Think. Jerome Groopman’s book is about the cognitive errors that can influence doctors’ judgments. What he consistently finds is that most doctors are unaware of the many cognitive pitfalls they face and their training does very little to educate them. Here’s one passage on the rush to judgment:
Most people believe that decisions in the ER must be made instantly, but [emergency physician Harrison] Alter said that “is a misperception that we doctors in part foster.” In order to think well, especially in hectic circumstances, you need to slow things down to avoid making cognitive errors. “We like the image that we can handle whatever comes our way without having to think too hard about it – it’s a kind of a cowboy thing.” As if being swift and decisive saves lives. But as Alter put it, he works with “studied calm,” consciously slowing his thinking and his actions with each patient in order not to be distracted or pressed by the hectic and sometimes chaotic atmosphere.
Groopman’s book is aimed at us as patients, but his lessons could be applied far more broadly. I can think of a bushel load of business executives that would profit from practicing “studied calm”.
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.
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.
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.