"Effective Medical Leadership:" Excerpts from Bryce Taylor's Book

University of Toronto Press 2010
ISBN 978-1-4426-4200-3; 240 pp

DECISION MAKING

Bryce Taylor

Of all the professionals in the world today, medical practitioners must be regarded as decision makers above all. Decisions must be made about the differential diagnosis of a patient's problem, the choice of appropriate investigations, the selection of a number of treatment options, and the continued follow-up of a patient's progress, including possible additional deviations in a planned course of action. In preparation for those responsibilities, medical faculties educate the future doctor by teaching the fundamentals of basic science; anatomic, physiologic, clinical, and pathologic states; and the advanced therapeutics of a vast array of clinical presentations. Some schools have even addressed the issue by using a problem-based learning approach. This methodology offers frequent practice in the assessment and solution of clinical problems from an early stage in medical education, but does it really promote understanding of the decision-making process that we will use every day? How does the human brain gather information in a standard history from a patient with type 2 diabetes, process that information (along with banks of remote and recently published evidence) in real time, recall years of personal experience with similar but not identical patients with the same affliction, draw conclusions about possible diagnostic possibilities, and then formulate a plan of action for the next steps? All of this may seem like a kind of medical kindergarten, but surprisingly few, including myself, have grappled with the understanding of our actual decisionmaking process.

Conventional teaching may imply that decision making is a mathematical process - information in, information processed along with other information, and then decision out - and some effective leaders may well succeed by using that approach consistently. But is that really the key to success? I guarantee you that most of the issues you will face as a medical leader will be like reading a new book: the players will be unique, the plot line will be interesting and convoluted, and the conclusion may well be in doubt until the very end. The only problem is that you may be faced with helping to create that end with your decisionmaking ability, and you have neither read that book before nor even heard of such a problem.

A must-read is a book by Jonah Lehrer entitled "How We Decide." In great detail, Lehrer describes what neuroscientists know about the chemistry of brain function, where decisions seem to be made in the brain, and which of the many factors appear to be important in the process. He describes the fact that our thinking requires emotional input, that our otherwise mathematical approach to solving complex problems requires feeling; he also reminds us that as humans we inherently practice a 'negativity bias,' that is, our fear of failure is a powerful motivator when we are making the tough decisions. If this is true, it places the medical leader in a most unenviable position. Taking the safe route to avoid the possible mistake or misguided approach to a problem may well not be in the interests of progress; bold, while potentially risky, may be beautiful!

Just as in morbidity and mortality rounds (see chapter 6), mistakes in management and leadership must be regarded as opportunities for learning. I have often said to my residents that the main reason I am a reasonably good surgeon with acceptable outcomes is that over the last three decades I have made every mistake in the book and tried to learn from each one of them. So too in leadership.

The feeling issue described by Lehrer takes me back to the issue of emotional intelligence ('Involving the "Troops" in Planning,' in chapter 2) and also the personality profiles of leaders ('Ensuring Quality of Patient Care,' in chapter 2). If you think of the typical ENTJ (1) leaders (the field marshals) in your past experience, were they ultimately more successful or less successful than the leaders who may have exhibited characteristics such as sensing instead of intuition, or feeling instead of thinking? Just a thought to ponder.

Being decisive does not necessarily mean that a quick forceful decision by a coercive (commanding) leader is your prime objective. A well thought- out decision with careful assessment of all the factors involved, using the appropriate input from colleagues and mentors and taking whatever time is necessary (within reason) for a fair evaluation, is, in the end, a reasonable approach, and if those steps become part of your reputation as a decision maker or leader, mistakes will be forgiven. However, just as in the clinical domain, mistakes must be reviewed and analysed, reasons illuminated, and lessons learned, and then you carry on with greater knowledge and wisdom than before.

Lehrer makes a number of observations that may help us as medical leaders to address the apparently complex problem in a more focused way:

1. We make decisions using our rational thought, with the prefrontal cortex acting like an orchestra conductor and our amygdala providing a kind of intuition or a 'wisdom of emotions.' The key is not to have emotions take over or to have too much faith in a rational approach and be overwhelmed with detail. Balance is the key.
2. We must avoid the assumptions that lead us to discount obvious facts; in other words, we must consider all options, even if they appear to fly in the face of our previous tightly held beliefs. Embrace uncertainty.
3. We should consistently think about how we think, and continually study our own decision-making process.
4. We should have faith that in our final decisions on a difficult topic our experiences will impart certain abilities and intuitions of which we may not even be consciously aware. This notion is at the root of Malcolm Gladwell's book "Blink", which emphasizes our innate ability to make complex judgments by using our intellect, our intuition, and our past experiences, while not even realizing that we are assimilating vast inputs into a single decision.
5. We should accept the fact that our decision making may involve moral judgments and that we may be bound by a feeling of what is right and what is wrong.
6. We should welcome dissenting views that can be tested against our own attitudes.
7. We should try to avoid being afraid of failure. No one likes to fail, but, as stated, the outcome of a less than ideal decision is an opportunity to learn.
8. We should remember that positive and happy people make better problem solvers; the rational brain is therefore not distracted by the noise of discontent, anger, and chaos.

I have often shared with friends and residents my own simple method for making tough life decisions, such as the acceptance of a new demanding position or perhaps a move by me and my family to a totally new environment and a novel opportunity, both social and professional. This approach is not revolutionary but happens to address both the thinking and the feeling aspects of the decision. First, I take out a sheet of paper and divide the page into two major columns representing the two options, for instance, staying in my city or moving to another organization in another state. Then down the left side I list every possible factor that my family and I can possibly think of when trying to reach a decision, stressing the advantages or disadvantages of each. Then I write down thoughts and feelings on the growing chart, being as specific as possible about the pros and cons of each choice. I carefully assign a 'value assessment' to each of the factors; for instance, being close to in-laws may be a very strong pro factor for staying or may indeed be a very strong pro factor for leaving!

This process so far follows the mathematical tendency of our brain in making calculated judgments. So now my chart is complete: it has the two major options, it has all the factors that weigh in on the final decision, and it has the relative importance of each of those factors. Now we're ready to get the calculator out and decide where we will be next year, right? Wrong! What I do now is, for me, the most important step, which by now may well be the easiest: I tear up the chart and make the decision. I believe very strongly that in such tough life-changing situations we need to carefully use our prefrontal cortex to evaluate all the factors that must be considered, discuss with trusted friends, verbalize and record in writing our thoughts and feelings, and then trust ourselves to make the right choice. Whether this can be termed in the end a gut feeling or a decision from the heart may be a subject for debate, but I believe it will be generated from the marriage of thinking and feeling that Lehrer talks about and will be appropriate for the circumstance.

Such an imperfect science as decision making is brought to bear every day in the life of a medical leader. Decisions are to be made carefully, with all the values held dear, including honesty, integrity, and caring about how the decision will affect others.

(1) extroverted, intuitive, thinking, judging

©Reprinted with the permission of University of Toronto Press (Selected sections of Bryce Taylor's Effective Medical Leadership will be reprinted from time to time in the Spotlight. Don't let this dissuade you from buying this superb handbook on leadership. Ed.)