August 02, 2013

How Doctors - and We - Think

Patrick Marren

Rereading Dr. Jerome Groopman's 2007 book How Doctors Think, a number of scenario-relevant statements jump out:

...We all tend to prefer what we hope will happen to the less appealing alternatives; this natural tendency is termed "affective error." We also lull ourselves into thinking that what we wish for will occur when we get the first inkling, however fragmentary, that our wish may come true. In short, we value too highly information that fulfills our desires.

[As Groopman says elsewhere, there is a mirror image of this tendency - to see the worst possible outcome as more likely than it is. This black/white tendency, to simplify things into "good/bad" dichotomies, then choose one - can be seen in business, government, intelligence, the military, and many other arenas. This is why multiple scenarios, systematically qualitatively and quantitatively differentiated, make so much sense. A black/white, good/bad dichotomy by its nature boils the world down to one dimension. For more secure decision making, and to avoid failures of imagination, we need to force ourselves to look at more than one dimension - and preferably more than two.]

...[A] fair question to ask an ER physician is: What's the worst thing this can be? The question is not a sign of neurosis or hypochondria; in fact, residents are trained to keep it in mind with each patient they see. But it easily can slip from the forefront of thinking in the intense environment of emergency care. By asking that question, a patient, friend, or family member can slow down the doctor's pace and help him think more broadly. You can prompt him to consider lifting his [diagnostic] anchor from the most available harbor.

[That said, when you are involved in risk management, you need constantly to remind yourself of the full range of plausible eventualities. That means not shutting yourself off from thinking about the worst case - as well as the best case, and several other possibilities. Asking yourself what is the worst thing that could possibly happen to your organization, what circumstances you definitely must avoid at all costs, is one way to focus your mind on what is strategically fundamental. Scenarios help with this - actually fleshing out the contours of the "worst case" can be quite liberating, because in our experience, "the worst case" often contains elements of opportunity that would be missed without thinking it through in depth.]

...A maxim I heard frequently during my training was "If it looks like a duck, walks like a duck, and quacks like a duck, then guess what? It's a duck." But it isn't always a duck. ...Physicians should caution themselves to be not so ready to match a patient's symptoms and clinical findings against their mental templates or clinical prototypes. This is not easy. In medical school, and later during residency training, the emphasis is on learning the typical picture of a certain disorder, whether it is a peptic ulcer or a migraine or a kidney stone. Seemingly unusual or atypical presentations get short shrift. "Common things are common" is another cliche that was drilled into me during my training. Another echoing maxim on rounds: "When you hear hoofbeats, think about horses, not zebras."

[One thing we have learned over several decades in this business is that the seemingly improbable occurs far more frequently than human beings think. We seem to have evolved to assume that little change will occur to our environment. This may have made some sense in prehistoric or medieval times; but this instinct is very dangerous nowadays. A 9/11, a 2008 financial meltdown, even a 1990s economic boom or a long-term decline in violent crime (such as we are experiencing since the early 1990s) can happen just when one least expects it. To paraphrase the Irish Professor John Pentland Mahaffy: "The world is a place where the inevitable never happens, but the improbable occurs often."]

...[Jay] Katz lumps [several] categories together under the rubric "disregard of uncertainty." ...As a law school professor, Katz knows that witnesses at scenes of accidents "unwittingly fill in their incomplete perceptions and recollections with 'data.'" There's a "pervasive and fateful human need to remain in control of one's internal and external worlds by seemingly understanding them, even at the expense of falsifying the data... Physicians' denial of awareness of uncertainty serves similar purposes: it makes matters seem clearer, more understandable, and more certain than they are; it makes action possible. There are limits to living with uncertainty. It can paralyze action." This is a core reality of the practice of medicine, where - in the absence of certitude - decisions must be made.

[The rubric of "disregard of uncertainty" is one under which many if not most managers operate today. The assumption that what has held true to date will continue to hold true tomorrow is a powerful one, especially because it almost always has successfully led those managers to the positions of leadership they occupy now. Managers who appear to be playing Hamlet, operating in uncertainty, rarely grasp the brass ring. And for a certain percentage of leaders, continuing these assumptions once they have grasped the reins will work out just fine. For many others, not so much. Scenario-based planning can test the assumptions under which you are operating and prepare you for conditions that could be quite different in the very near future.]