On Blinking

"Blink," Malcolm Gladwell's fantastically popular book about the mysterious workings of the human mind, is gaining favor with the physician community.

I've already talked to executives who have included "Blink"-based exercises in their corporate retreats. And as many of Gladwell's illustrative anecdotes come from healthcare and seem to inform the current debates over the efficacy of practice guidelines and pay-for-performance movements, it's worth tuning into.

Gladwell's main point: Your brain does its own thinking. You know things when you don't even know why you know them. Skilled museum curators just know a fake sculpture when they see it even if they can't pinpoint right off what's wrong. Tennis aces can predict a double fault the moment their opponent tosses the ball in the air to serve. In fact, thinking about things too much can actually get in the way of good decision-making - just as it can get in the way of a good time. As Gladwell puts it, "Decisions made very quickly can be every bit as good as decisions made cautiously and deliberately."

It's no surprise that a book on this topic is replete with examples from healthcare. I've been chatting with physicians about their "Blink" sense and most feel their sleep-deprived training and years of practice do give them useful intuition. They just know how deep to cut, how to maneuver around unusual anatomy, whether a patient's weight loss is something serious. It's this artful, nearly inexplicable side of medicine that makes practice guidelines and pay-for-performance measures so annoying. Sometimes you know better than the guidelines, even if you can't articulate why.

Of course, sometimes, physicians don't know better. Their insight misleads them.

Gladwell provides this example: The emergency department at Cook County Hospital in Chicago had a problem with chest-pain patients. It was hard for physicians to tell which patients were truly in distress and which had gas or some other minor issue. The patients crowded desperately needed beds, and physicians put each patient through a long treatment protocol that often didn't clarify much. After asking questions about diabetes and cholesterol, listening to the heart, and running an ECG, physicians basically made an estimate of the level of risk based on their intuitive sense of things. The problem was that the estimates weren't very good.

"The same patient might be sent home by one doctor and checked into intensive care by another. ... The doctors thought they were making reasoned judgments. But in reality they were making something that looked a lot more like a guess," Gladwell writes.

However, when the physicians based their decisions on just three factors - Is the pain unstable angina? Is there fluid in the lungs? Is the systolic blood pressure below 100? - they caught true heart attacks 95 percent of time. The better solution came from less information, not more. The new model was based on less data, less analysis. But it showed that spontaneous, impulsive decisions need to be based on the right data.

The anecdote has interesting parallels in the management of your office. On the one hand, many of you are suffering from analysis paralysis. I've talked to physicians who clutch spreadsheet after spreadsheet, create an internal response to every piece of pending legislation, and have every technology imaginable. Yet they are still billing for only 75 percent of the services they perform.

On the other hand, too many groups have basically no information to work from. They make business decisions impulsively, and it leads them astray. I think of the groups who are always backed up in the waiting room, double-booking patients. The physicians yell at the schedulers and the schedulers blame the patients who think everything is urgent. Everyone ignores the fact that they don't have nearly enough physicians to handle their huge patient panel.

It will come as a shock to no one that the ideal is somewhere in-between these extremes. The relevant question is how to determine what data drive the right clinical and business decisions. That's a question too often overlooked these days. If success were as easy as prescribing a few rules or hoping for the best, practice management would be a lot easier.

What do you think of the role of instinct in the practice of medicine? Tell me at pmoore@physiciansprtactice.com.

This article originally appeared in the October 2005 issue of Physicians Practice.