How do we make daily decisions in our careers?
In my field, physical therapy, we use the term clinical decision making (CDM) — “a highly complex, multi-faceted skill that is developmental and requires a substantial amount of practice with realistic patients to develop.”
As a physical therapist, I rely on current research to make clinical decisions. As an orthopedic residency program coordinator and faculty member, I teach the latest evidence and techniques to novice clinicians.
Each year I acquire more experience and knowledge. As the gap between my performance and the latest batch of new graduates expands, I recognize the information I have acquired is not the differentiator.
It is how I make clinical decisions.
We often think our decisions are well-reasoned and logical. We believe they are rational.
Rationality can be defined as “acting in a way that helps us achieve our goals.” As a physical therapist, the goal is typically improving health. We want to make the best decision for the patient, but it requires more than knowing the latest research.
Decisions and rationality are supposed to go hand in hand. Yet, our emotions are often the decision-makers. Consciously, we believe we are making a rational decision, but research is clear when it comes to decision making, rationality often falls short.
Once I started learning about decision-making theories and bias, my clinical practice reached a new level. Now when I teach, decision-making takes center stage.
Here is how I teach clinicians and students to make better decisions, regardless of their careers.
How do we make decisions?
“Successful decision making relies on a balance between deliberate and instinctive thinking.” — Blink by Malcolm Gladwell
As a new graduate physical therapist, I made a remarkable amount of blunders. Thanks to the Dunning-Kruger effect, I was blissfully unaware of my errors in thinking at the time.
As I have acquired more knowledge and experience, I realize my decision-making was flawed.
I am not unique.
Everyone is susceptible to errors in decision-making. Without a sound foundation in decision-making strategies, the information and experiences we gather will be of limited value.
There are two primary models of decision-making supported in the research: Fast and Frugal and Dual Process. The Fast and Frugal method involves our gut reactions and decision-making shortcuts. Rapid decisions are often necessary, but is faster better?
To make rapid decisions, we often rely on intuition, a gut feeling. Is that a reliable way to make decisions? Sometimes.
The fast and frugal model has limitations
“The prize is the pleasure of finding things out, the kick in the discovery, the observation that other people use it.” — The Pleasure of Finding Things Out by Richard Feynman
The Fast and Frugal system, first proposed by German psychologist Gerd Gigerenzer, emphasizes quick decisions drawn from our intuition.
The frugal part refers to limiting the information we use. More information often confuses us rather than helps us. To assist with frugal decisions, we use heuristics — decision-making strategies.
The goal of heuristics is to improve our decision-making by filtering out unnecessary information and taking shortcuts. Fast and frugal decision-making relies on decision-making trees and intuition.
When we develop expertise, intuition — or gut reactions — becomes more common. We can experience intuition in a job, sports, or a relationship. It is a feeling deep down that urges us to take action. What is fascinating about gut reactions is we struggle to explain them.
When asked why we made a particular decision, we are unable to provide a concrete answer. In his book Blink, Malcolm Gladwell describes many of these situations.
Gladwell describes situations when art curators can spot expert forgeries within seconds of viewing a piece from several feet away. When asked how they knew, often they are unable to articulate the exact reason. It was a “gut” feeling. Upon closer examination, given time, they can explain the specific signs of the forgery. Similar experiences can be found across the professional spectrum.
Intuition has been defined as “the ability to understand immediately without conscious reasoning and is sometimes explained as a ‘gut feeling’ about the rightness or wrongness of a person, place, situation, temporal episode or object.”
Intuition requires synergy between knowledge, experience, and expertise. While intuition can be a powerful ally during decision-making, it will be limited in novice professionals. A lack of experience will limit the number of experiences a clinician can draw upon when making clinical decisions.
By relying on limited experiences and limited information, fast and frugal decision-making lends itself to more errors.
In a crisis, delayed decision-making can be detrimental. Fast and frugal is a great strategy for emergency department physicians and paramedics, who often lack the luxury of time to reflect and weigh options. They need to make decisions on a limited set of information.
As a physical therapist, I do not have to make life-or-death decisions. But my decisions still impact a patient's overall health and wellbeing.
Many of our decisions do not need to be flawless, but rather, they need to be good enough. That is the heart of fast and frugal.
But what if you are not rushed for time. What if you or your people lack sufficient experience and expertise for reliable intuition. The dual-process method becomes the method of choice.
Sometimes slow thinking is best
Dual-process theory, proposed by Daniel Kahneman and Amos Trevesky — splits decision making into two processes — intuitive (system 1) and analytical (system 2).
System 1 is similar to the fast and frugal approach. These fast, automatic decisions rely on thin-slicing — the ability to find patterns in situations based on limited amounts of information.
Most of our decisions and behaviors stem from system 1 thinking, regardless of our conscious awareness. While effective, system 1 thinking is prone to bias — the error in heuristic-driven decision making.
To combat bias, professionals can employ system 2 decision-making. System 2 is the methodical and analytical decision-making process.
Professionals test hypotheses, assess all relevant information, reflect on past decisions, and deliberate future action. It is a reliable, safe, effective, but slow process.
System 2 fills the gaps where intuition falls short.
For any professional with less than 5–10 years of experience, intuition is limited. They simply haven’t built the memory bank of experiences. If they try to use simple heuristics, they will miss valuable information. If they rely on their intuition, limited information and cognitive bias will lead them astray. We need another method for improving our decision-making.
“Intelligence is not only the ability to reason; it is also the ability to find relevant material in memory and to deploy attention when needed.” — Thinking, Fast and Slow by Daniel Kahneman
Recognition and timing are key to decision-making
Pat Croskerry, the developer of the dual process method, explores the influence of cognitive bias in medicine. He lists three requirements for clinicians to optimize clinical decision-making. These strategies apply to all careers.
- Acknowledge the influence of bias and your susceptibility to cognitive errors when making clinical decisions
- Understand errors are not inevitable
- You Must remain vigilant and believe solutions to reduce bias are viable.
This article and the resources included serves as step one: acknowledging bias.
One of the best tools for navigating biases is reflection. Effective reflection involves consciously reflecting on alternative interpretations and solutions.
Force yourself to list the alternatives, even if intuitively they seem far less likely. This ‘cognitive forcing’ temporarily contains cognitive biases, particularly confirmation bias — the tendency to accept information that confirms our current beliefs and rejects information that refutes them.
To enhance your reflection, gather external opinions from colleagues and mentors. We are limited by our perspectives and experiences. Building a collaborative approach — avoiding groupthink — can refine our decisions.
As you build experience and develop reflection habits, the time and effort required to make future decisions will decrease. Do not become complacent, however.
No level of experience or study will ever make you immune to cognitive bias and decision-making errors.
“Scientists must be able to answer the question “What would convince me I am wrong?” If they can’t, it’s a sign they have grown too attached to their beliefs.” — Superforecasting by Philip Tetlock and Dan Gardner
It is not only scientists who need to ask themselves that question.