Decision Paralysis

 Part of a series of articles for BJS Academy

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Several years ago a corridor conversation changed the way I thought about surgery and surgeons. Talking with a surgical colleague, the chat ended on the topic of physical dexterity and procedural competence. I explained that my physical ineptitude drove me away from inventional radiology. It is also why I don’t do DIY. Whether I’m trying to cannulate a femoral artery or screw something to a wall, I’m hopeless. I’ve got hands like cow’s udders.

My colleague smiled politely, “But, Paul, operating isn’t about dexterity, it is about decision-making”. They reasoned that anyone can become proficient in a physical skill, even cack-handed muppets like me. They further explained that procedural success is not about psychomotor slickness but dynamically modifying your operative technique based on experience and knowledge. Which also involves knowing when to stop. Or not even operate at all.

This conversation stayed with me. It explains why tests of physical dexterity have never correlated with overall ability of a surgeon. It didn’t reawaken a desire to move sideways into interventional radiology - patients are still better off without me advancing towards them wielding a dirty great needle. I did subsequently read up on clinical decision-making and it’s pitfalls. I even wrote a whole chapter about it in my first book. 

Given that clinical judgement is so central to our practice, it is odd that it is not explicitly taught or learnt. We just pick it up as we go along. But a lot is known and can be taught. And it is helpful to understand it so as to be aware of the pitfalls. 

The majority of our decisions are subconscious and semi-automatic, a product of the so-called ‘chimp brain’. Called ‘type I thinking’, such rapid decisions take milliseconds and take zero cognitive effort. It gives snap judgements hence is potentially flawed. But some decisions are a result of ‘type II thinking’, where we consciously engage the grey matter. 

We understand the type II thinking involved in clinical judgement. Most of us have heard of deductive reasoning. We all know about Sherlock Holmes and his expert deductions. I was vaguely aware of inductive reasoning, where facts are uncertain and probabilities are required. But I’d not heard of abductive reasoning before. This is, as it turns out, what doctors actually do. We use hard evidence to deduce the facts as far as we can and then make a best guess through inductive reasoning thereafter. 

One example of abductive reasoning is the Duck Test; “If it looks like a duck, swims like a duck, quacks like a duck, then it probably is a duck”. Or as Douglas Adams parodied, “We have to at least consider the possibility that we have a small aquatic bird of the family Anatidae on our hands”.

Although it doesn’t sound terribly precise, best guesses through abductive reasoning are the meat and drink of clinical practice. Abduction isn’t perfect but gives fairly decent results if used by an expert who is knowledgeable and experienced enough to avoid common cognitive biases. And by knowing about this, we can teach others how to do it too.

Yet there is a paradox. We know so much about how doctors make decisions. And we know how crucial decision-making is in successful clinical practice. But decision-making is at an all time low. Decision paralysis is rife across hospitals, surgery very much included. Patients languish on wards, no one makes decisions. Surgeons seem to do everything other than operate. Surgical inpatients have so many CTs these days that their treatment seem to largely consist of low dose radiotherapy. Plus IV antibiotics, of course. 

It wasn’t always thus. There is an old joke that on passing their surgical fellowship, new fellows were offered a small tincture that obliterated a small section of the brain that dealt with self-doubt. The physicians have a similar mythical liquid that scrambles knowledge of anatomy on gaining their MRCP. It is equally fictitious but I can’t explain it any other way.

Anyway, irrespective of the toxic effects of RCS sherry, surgeons of yore were historically untroubled by indecision - “rarely correct but never in doubt”. And, back then, the word of the consultant surgeon was law. Such decisions were final; not up for debate. Surgeons enjoyed higher status; very much top of the hierarchy. And rightly so; they were the ones who everyone turned to in an emergency. 

Of course, it was a different time; a simpler time. The decisions were usually three fold: 1) masterly inactivity and hawk-like observation; 2) lift up the metaphorical bonnet up and have a rummage around or 3) dump the patient on the physicians. It could be argued that matters are haven’t changed much, except 1) is interspersed by regular CT and 2) is less rummaging and more focused intervention (but dependent on CT) and 3) has been rebranded ‘shared care’.

Modern expectations of behaviour are different. To be honest, it was always a fine line between a surgeon known for making rapid decisions and a surgeon who was a notorious psychopath. Psychopaths aren’t tolerated anymore. We want surgeons who listen and are open and honest. And cry at films. That kind of thing.

A modern surgeon is no longer medical royalty. If the brown stuff hits the fan, they call anaesthetics, radiology then surgery; very much in that order. Surgeons have to be genuine team players. They have to acknowledge the existence and opinions of oncologists and radiologists. Patients want a big say in their treatment too. Any surgeon who rail-roads decisions over their patients and/or colleagues will soon be meeting their medical director then spending a lot of time in their garden, on enforced leave. 

So what is the answer to the latter-day epidemic of decision paralysis? Well, it isn’t easy. You get stick for being too timid or too bold. But this is the job and we shouldn’t back down from offering an opinion or making a decision, accepting that we’ll sometimes be wrong and have to live with the consequences. 

This notwithstanding, surgical decision-making is a helluva lot easier with a trusted radiologist buoying you up. But it works both ways. UK radiologists need your support too; we are struggling too, more than you’d know. So, help us to help you. Then everyone wins.