Where is the horse and the rider?
Where is the horn that was blowing?
They have passed like rain on the mountain,
like wind in the meadow. The days have gone
down in the West behind the hills into shadow.
How did it come to this?
Theodin King, Two Towers
I do not understand what I do.
For what I want to do I do not do,
but what I hate I do.
Romans 7:15
Our decision making process is a mystery. Bummer that because that process impacts everything from how we choose to spend, save, invest our money, to how a doctor counsels a patient, how a lawyer counsels a client, how a pilot lands a plane. Knowledge isn’t enough, skill isn’t enough. Our decision-making process is complex and fallible. In the world of personal finance there is Why Smart People Make Big Money Mistakes by Belsky and Gilovich. In general decision making there are Blink by Malcolm Gladwell and How We Decide by Johan Lehrer. In the world of medicine there is The Checklist Manifesto by Atul Gawande, MD and How Doctor’s Think by Jerome Groopman, MD. As a society we think about how we think and with good reason. How we think, what we decide and the actions that flow from those decisions will ultimately determine where we land in life. Dr. Richard Friedman’s essay Sabotaging Success examines a tendency that some people have to engage in masochistic behavior.
As a physician I am especially concerned with medical errors. Gladwell’s thesis is that decisions occur on a near intuitive level defying explanation. That intuition is influenced by experience. Lehrer proposes that it is emotion that occurs on an unconscious level that informs our decisions and Dr. Gawande argues and, I tend to agree, that the decision process is flawed so we need to have a system of simple and efficient checklists to facilitate good outcomes.
In the world of personal finance it is easy to say that we don’t save because we don’t know we should save or how to do it once we understand that we need to do it. You cannot walk into a book store without running into a personal finance book. You read, not one, but 10 and you have the knowledge that you should save and even a clear idea of how to do it, but you don’t. Now you are up against how you decide to do what you do. This is the hardest thing to accept: knowledge is not enough to affect the decisions we make or the actions we take.
In the world of medicine it is easy to counsel a young physician who makes a mistake because we can chalk his mistakes up to both ignorance and lack of experience. What do we do with a physician
with over 20 years of experience who makes a basic error that leads to patient harm? Because decision making is complex, the answer to what do do is equally so.
We may never understand how we decide. Our brains are a series of neuronal connections awash in chemicals. Knowledge, though necessary, is not enough and neither is repetition. Yet we cannot make good decisions without them. Is developing emotional intelligence, the ability to govern our emotions and act in the face of them, the answer? It is certainly an answer, but, in all likelihood is not the answer. What do we do, then? We should accept how complex our decision making process is and that it may represent a complexity that “passeth understanding”. We should continue to gain knowledge and skill. Finally, we should understand that faulty decisions will occur and try to learn from them.
What are your thoughts? Please comment.
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