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MEDICAL PRACTICE
STRATEGIES & ISSUES

Physicians as Leaders –

Six Ways to Ruin a Decision

By Robert Hromas, MD, FACP

Medicine is a team sport. The lone physician delivering babies decisions, comes from their studies.
and taking out gall bladders in a small town is rare. Medicine has The first mistake is that we mistake anecdote for data. These
become so complex that it requires many types of health care anecdotes can be our own experiences or those of someone else
providers, not only many medical specialists, but also nurses, dieti- we trust. Kahneman and Tversky showed that most of us have bad
cians, social workers, pharmacists, techs, administrators, and the cus- intuition of the laws of chance. We readily assume a small sample
todians and maintenance workers that keep the clinic or hospital randomly drawn from a population is highly representative. We
clean and functional. think it is similar to that population in all essential
leading these teams requires accurate solutions to complex prob- characteristics, even characteristics we have
lems. If you make a mistake, it can harm the entire team. Sometimes not directly measured. Thus, we expect
decisions are required rapidly, either there is an opportunity that is that drawing another sample from
fleeting or there is a problem so large it requires immediate atten- the same population will be sim-
tion. Usually, this kind of decision has even higher risk for everyone ilar to the first sample, and
involved. similar to the population.
despite the risk of making a mistake and harming the team, or We extrapolate from
worse, your patients, few physician leaders think much about the small samples to make
science of decision making. There has been great deal of research future predictions.
on how we make decisions, and it is not reassuring. Our experience Worse, we use our
is often wrong, as we are all anchored by the emotions we attach to own experience as
past experiences, which commonly have little relationship to what that small sample
actually happened. Worse, we rely on our instincts, which means of the population.
that we forsake real data for our own likes and dislikes. For example, If it happened to
if we really like the person who is on one side of the decision, then us, we extrapolate
our instincts will favor that side of the decision. to the entire popu-
Even if we recognize our bias in making a decision, and do our lation. For exam-
best to contain it, we will often fail because the very fact that we ple, if I flip a coin
identified the bias makes us too comfortable. We falsely reassure and it lands heads 4
ourselves that our decision is now unbiased and we can proceed times in a row, I feel
without caution. that the fairness of the
There are seven common mistakes in making a decision that are coin entitles me to ex-
easy to make, and I have made them all. Unless I am conscious of pect that any deviation in
how these mistakes can worm their way into my thought process, I one direction will soon be
will be shocked when things go wrong. The field of behavioral eco- cancelled by a corresponding
nomics has been at the forefront of research into faulty decision- deviation in the other. This is not
making and has resulted in the Nobel Prize for Economics for dan the case. Coin flipping does not make
Kahneman. This prize also honored his long-time colleague, Amos up for its past behavior. There is a 50%
Tversky, who died of melanoma a few years before Kahneman won. chance every time the coin is flipped that it will be
One of their later collaborators, Richard Thaler, famed for his prin- heads again. This mistaken belief in “fairness” is why the
ciple of Nudging, also won the Nobel Prize just three years ago. compulsive gambler keeps betting even after losing a great deal.
Much of what I write about below, on the seven mistakes that ruin The second mistake is letting the wrong person make the deci-

16 San Antonio Medicine • January 2020