The Art of Choosing: One Mental Hack for Better Clinical Decision Making.

“Where is the wisdom we have lost in knowledge?  Where is the knowledge we have lost in information?” - T.S. Elliot in his poem The Rock.

 

 

Why it matters?

 

Choosing matters to us as clinicians, whether you're a doctor or nurse, an EMT or a paramedic.  Regardless of your title, if you are engaged in patient care on a regular basis and are tasked with making decisions then this mental hack will help you.  

 

Our choices in patient care may not define the entirety of who we are, but our decisions at the bedside sure determines the kind of clinician we have chosen to become.  Our decisions matter and we make decisions even when we don't realize it. A lot of our decision-making dialogue is highly internalized.  

 

Talking to yourself: What does it mean?

 

One of the questions you may ask silently again and again is: Did I make the right choice? When I took care of patient ABC with XYZ problem suffering QRS circumstance? Did I make the right choice? Did I do the right thing? Could I have done something better? Work in healthcare long enough and inevitably you find yourself asking questions of this nature.

 

Asking yourself this type of question just means you care.  You care about the mission.  You care about doing better.  If you're not asking yourself these types of question then take a moment.  Ask it of yourself. 

 

Choosing & Fatigue

 

In a single work shift you are constantly faced with making decisions and choosing from literally dozens of paths. The work of choosing can wear you down.  It can create something called cognitive fatigue.  

 

In modern life you are surrounded by tons of choices. You know, 30 different types of a tomato sauce and 22 different soft drinks to choose from at the supermarket. 

 

You probably have 10 or 11 different varieties of power drinks alone you can select to help stay awake for those long hard shifts. You're surrounded by choices and sometimes you’re just overloaded by the menu of possibilities. 

 

You can become paralyzed by the number of options. 

 

Anybody who's ever done a home remodel can understand. Head over to the nearest hardware store and the designer plunks down a huge book on the table in front of you. Next thing you're flipping through hundreds of pages of various kitchen tiles- different colors, textures, styles. 

 

Could you imagine that? Hundreds of pages of different tiles for just one room?  Do you feel your brain shutting down imagining it? It’s just too many options.  When faced with disproportionate complexity relative to the simple task at hand it seems your brain can become overworked and tired.  

 

 

Sharper Decisions

 

But in taking care of people that need our help in health care, at the bedside, in the streets, in the back of an ambulance, wherever you happen to be, there is no time for paralysis. You have to decide. 

 

Sometimes you have to decide between good and bad choices, or you have to decide between a bad choice and a horrible one.  There is really no dilemma between a horrible choice and a good one.  

 

Half decent training can get you through moments where the better choice is obvious.  Other times several acceptably good choices are presented and you may have to decide which is the better option.  Or you may be called to select the least harmful of a number of bad choices.  

 

It is in this space that our craft is either sharpened or dulled.  Experience becomes the differentiator.  

 

Are you an expert?

 

Have you ever heard of this definition of an expert?

 

An expert is a man [or woman] who has made all the mistakes that can be made in a narrow field.”  -Neil Bohr    

 

Sometimes you don't make the right choice because quite honestly, you don't realize that that there is a right choice or you don't identify the right choice or maybe there just isn’t a right choice! Whichever way you think about this, the act of deciding can produce frustration, pain- sometimes even agony. 

 

I recently listened to an interview with researcher and academic Sheena Iyanger where she insightfully pointed out the strife of choosing reflects a struggle between  “heart versus mind” or “gut versus reason”.  Professor Iyanger points out with regard to making decisions you ask yourself two basic questions:  “What do I want?” And, “What should I choose?”  

 

Similar questions can be asked in your clinical decision-making thought process:  “What would I like to do for this patient?” And, “what should I do for this patient?”  The answers to these queries can be divergent.

 

Often the answers to these questions do not align, but the latter question helps you check bias at the door.  It’s your “out”, so to speak.  You give yourself permission to set aside your skepticism, fatigue, disbelief or just silence your BS meter long enough to get the work of your profession done without all that angst inside.

 

Always a Padawan: The Forces Are Within You

 

On a daily basis, the two forces of “gut versus reason” create inherent conflict in clinical decision making.  But you may notice some people struggle more than others. Early in my career after residency, I had an elder physician who looked over my shoulder from time to time. On occasion while working overlapping shifts he would see me in the corner really struggling to make decisions.  Sometimes I’d run the case by him, using him as a sounding board.

 

This wise elder physician used four words that really changed my way of thinking and delivered me from the angst-ridden state of young physician life.  He said, “Do what is medically correct”- full stop.  “If you do what is medically correct you will always align yourself with your patient’s interest.”  

 

It was great advice early in my career that helped me reframe the experience.  Let's be honest, sometimes it is difficult to comprehend the motivations that drive some people to access medical care.  Most are honestly looking for help, but a significantly sized group are driven by alternative motives.  

 

 
Still others come in with genuine complaints, but they may behave in a way that we don't understand.  You can misread the signs of their external behavior and in doing so you can make a critical mistake.  We’ve all been there at some point in our trajectory- if even for a minute. We have had thoughts like:

 

I just want to bounce this person out of the emergency department, or

 

You don't really require transport by ems to the hospital, or

 

I'm just going to ignore this patient because they’ve been riding the call button every five minutes.


 When internal strife emerges from the struggle of “gut versus reason” it is helpful to ask: what is the medically correct thing to do? (aka What Should I do? >> What do I want to do?) 

 

 

Conclusion

 

Nobody in healthcare shows up to do a mediocre job. You go to work in healthcare because you want to do a good job. You want to serve people. You want to do the best job possible, but the landscape in modern day healthcare is fertile with influences that fray on your ability to consistently make high quality decisions.  

 

Understanding this fact is critical to shaping the clinician you decide to be.  Using a simple thought exercise as described in this article can make a significant difference.


About The Writer:  Hector Caraballo, MD is a practicing Board Certified Emergency Physician and Chief Medical Officer at MedCognition.


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