One of my favorite questions to ask fellowship applicants is what skills they think are important to be a good pediatric emergency physician. Almost all of them respond with something along the lines of being able to multitask, building and leading a team, and maybe procedural skills. When I point out the importance of those skills for almost any specialty, and ask for those skills somewhat unique to our field, many draw a blank. To my mind, one of the unique skills of an emergency physician – indeed, one of the defining features of the specialty – is the ability to make decisions with incomplete information.
Of course, no one ever has truly complete information, but the limitations due to time and resource constraints in the setting of the ED are much greater. Physicians have to determine and commit to a plan of action despite the fact that the patient’s history may be limited by the absence of a caregiver, or a prior relationship with the patient and family; some tests may not be available in off hours, and results of tests that are performed may not be available until after the decision has to be made; and competing demands more significantly limit the amount of time we can spend with a patient than in a scheduled setting.
Comfort with making decisions in the face of incomplete information, and being able to do so with an appropriate level of confidence, is a critical skill for the emergency provider, but is useful in a variety of contexts. For example, business leaders must often make strategic decisions vis a vis their competitors without good intelligence on what the competitors’ plans are. In a rapidly evolving healthcare environment, hospital and other leaders face a number of key decisions that will have impacts for years, when we don’t have a good deal of information about what the environment will look like even months from now.
This skill requires some humility: the less information you have when you make a decision, the more likely it is to turn out to be a bad one. It also requires a thick skin, as the next-morning quarterbacks are all too happy to wonder aloud about what those people in the ED were thinking. I have long contended that, although some people may never be comfortable with making decisions in the face of incomplete information, most of us are capable of doing so, and that it is a skill that can be developed through practice. Recently, I read a fascinating book about decision making by the Nobel Prize-winning economist Daniel Kahneman that provides some support to this. Thinking, Fast and Slow – about which I will comment more on in future posts – describes the two systems in our mind that are involved in decision making. System 1 (in Kahneman’s terminology) is the one that allows us to form immediate impressions, take automated actions. It is responsible for snap judgments. As such it performs an important function (our forebears would have had a hard time if they had to do a thorough risk analysis every time they were chased by a large carnivore) and usually does pretty well, though it is subject to a variety of biases. System 2 involved the slower, more conscious and overtly analytical processes that provide a check and oversight over System 1. One could surmise that making decisions without complete information might involve suppressing System 2, allowing us to go with our gut impressions. But in fact, it turns out that, again in Kahneman’s words, system 2 is “lazy”. The challenge is not to suppress it, but to invoke it. I suspect most of us realize that our gut impressions are subject to bias. It’s why we have sayings like “don’t judge a book by its cover,” and why we abhor racial profiling. As a result, I believe that we are suspicious of our System 1 judgments, and overcompensate by insisting on a thorough System 2 review before committing to anything. Being able to rapidly do a System 2 check of System 1’s snap judgment, and recognizing the strengths and limitations of both, is key to successful decision making with incomplete information.
It can be a challenge to efficiently bring our System 2 to bear on decisions that seem time sensitive, especially when there are many such decisions to be made in a brief period. Interruptions and distractions, things that keep us from focusing attention, will tend to degrade the quality of decisions. The ED is rife with those distractions. It requires a certain amount of mindfulness, of “being here now,” to use our System 2 most effectively. It is that mindfulness that we can exercise as a way to make better decisions when we do not yet have all the facts.