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April 17, 2017

The author of 'Moneyball' on how doctors can think differently—and save lives

Daily Briefing

At one of Canada's busiest trauma centers, a respected internist pushes doctors to challenge their assumptions about human decision-making—and save lives in the process, Michael Lewis writes in an excerpt of his book, "The Undoing Project," published by Quartz.  

Lewis' book focuses on the working relationship between Daniel Kahneman and Amos Tversky, a pair of Israeli psychologists who 40 years ago released a series of groundbreaking studies on human decision-making. In work that was foundational to the field of behavioral economics, Kahneman and Tversky showed how the brain systematically makes mistakes when dealing with uncertainty, fails to process statistical information in a meaningful way, and lets intuition lead it astray.

Quartz recently published an excerpt from the book that explores how behavioral economics informs Don Redelmeier, an internist who plays a critical role at Sunnybrook Hospital, one of Canada's busiest and best-regarded trauma centers. Using Kahneman and Tversky's research, Redelmeier helps doctors think differently—and avoid costly mistakes, Lewis writes.

The watchman

Rob Fowler, an epidemiologist at Sunnybrook, says, "It isn't explicit but it's acknowledged that [Redelmeier] will serve as a check on other people's thinking." He helps keep other doctors "honest."

Most of Redelmeier's attention is focused on clinical decision-making failures. "Wherever there is uncertainty, there has got to be judgment," he explains, "and wherever there is judgment, there is an opportunity for human fallibility."

There are many reasons why doctors make bad decisions, Lewis writes. He points out that physicians might not realize that a patient's assessment of his or her condition is unreliable, or they might be predisposed to treat the most obvious condition, "oblivious to the possibility that some less obvious thing might also be wrong with [a patient]." He writes, "Doctors [tend] to pay attention mainly to what they were asked to pay attention to, and to miss some bigger picture."

Jon Zipursky, chief of residents at Sunnybrook, says Redelmeier pushed him to become a better observer so that he doesn't miss the big picture. Redelmeier advised Zipursky to look for details such as a patient's meal tray (to see whether they were eating), and the size of their bag (to understand whether they had planned for a long hospital stay).

But some clues aren't hiding in plain sight.  

Not so obvious after all

Lewis recounts the story of a woman who was brought to Sunnybrook after a bad car accident, suffering from multiple broken bones. "But it was only after she arrived in the Sunnybrook operating room that they realized there was something wrong with her heart," Lewis writes.

Her heart rhythm was dangerously irregular. Redelmeier was called into the OR to make an assessment, but by the time he arrived, the OR staff had decided they knew what the problem was: The women had said she had a history of an overactive thyroid, which can cause an irregular heartbeat.

"No one in the operating room would have batted an eye if Redelmeier had simply administered the drugs for hyperthyroidism," Lewis writes. "Instead, Redelmeier asked everyone to slow down … to check their thinking."

Redelmeier, Lewis writes, wanted to make sure that they weren't trying to fit the problem into a tidy, convenient narrative. "Hyperthyroidism is a classic cause of an irregular heart rhythm, but hyperthyroidism is an infrequent cause of an irregular heart rhythm," Redelmeier later explained. The staff had made a quick, seemingly logical conclusion without considering more likely causes of the cardiac issue.  

Redelmeier told the staff to search for other causes—and that's when they discovered the collapsed lung the X-ray had missed. Treating the collapsed lung fixed the heart arrhythmia. Later, the woman's thyroid hormone tests came back normal.   

Redelmeier said it was a classic case of flawed clinical decision-making. "Eighty percent of doctors don't think probabilities apply to their patients," he said.

The OR staff missed the collapsed lung because they used a "representativeness heuristic"—or a mental shortcut. "You need to be so careful when there is one simple diagnosis that instantly pops into your mind that beautifully explains everything all at once," Redelmeier explains.

"Inside a hospital, or really anyplace else, Redelmeier was never completely certain about anything," Lewis writes. "And he didn't see why anybody else should be, either" (Lewis, Quartz, 12/6; W.W. Norton & Company, accessed 1/11; Dutcher, University of California Berkeley, 3/28/14; Holt, New York Times, 11/25/2011).

Are you leading an evidence-based organization?

Despite the shift toward broad acceptance of evidence-based practice (EBP) among medical staff, over half of physicians report not actually using guidelines day-to-day when they are available. As a result, organizations continue to see tremendous variation in clinical practice—as well as in costs and outcomes.

Our infographic outlines four principles you can use to support EBP at your organization, along with action steps to implement each one and pitfalls to avoid along the way.


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