A Look at Irrational Decision Making In Medicine

A LOOK AT IRRATIONAL DECISION MAKING IN MEDICINE

How often have you seen seemingly rational and experienced clinicians do something completely irrational and out of character like overlook an obvious diagnosis.

Our guests today say there is an irresistible pull of irrational behavior driving their behaviors.

Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt, your host, and with me today are Ori and Rom Brafman. Ori is coauthor with his brother Rom Brafman of Sway. His previous book The Starfish and the Spider won glowing praise from business and general publications alike. He is an MBA. He is a life-long entrepreneur who launched a network of more than a 1000 CEOs. Rom Brafman holds a doctorate in psychology and has taught university courses in personality and personal growth. He won the University of Florida Social Sciences graduate teaching award and the <_____> Human Growth and Development award. He practices in Palo Alto, California.

DR. LESLIE LUNDT:

Welcome to ReachMD, Ori we'll start with you.

ORI BRAFMAN:

Thanks for having me.

DR. LESLIE LUNDT:

In your book "Sway" you give an example of an ER case, let's go over that today.

ORI BRAFMAN:

Sure, this is one of the stories that actually led us to write the book. A woman and her child came into the emergency room and the child was complaining of severe stomach pain and the doctor started taking a look and they looked up the kid and the mother and what they noticed is that the mother in the file was flagged as a frequent flier, that is a woman who made many emergency room visits and often times was complaining about stuff that wasn't really an emergency, and instead of diagnosing the kid, they ended up diagnosing the mother, and they figured, you know what this mother is just overreacting, they sent the kid home. The next day the kid and the mother show up again and the kid is still complaining of severe stomach pain and again they look up the mother’s record and see that she is a frequent flier, tell them that it's not a huge deal, go home. The third day, the daughter shows up with the mother again and this time her condition becomes very, very serious and ultimately it turns out that the child actually died in the emergency room and you wonder how could the doctors miss a diagnosis, how could they not run the appropriate tests and what happened was that instead of diagnosing the child, the doctors ended up diagnosing the parents.

DR. LESLIE LUNDT:

Rom, why would an experienced team of doctors make a decision that contradicts all of their training and experience?

DR. ROM BRAFMAN:

Well, I think that's the difficulty of being a physician or being a psychologist, especially when you are handling crises is that you have a lot of guess going on, you've got a lot of new information that have to sift through and you have to make decisions really fast and as human beings, our brains are programed to want to know what's going on. We don't like chaos, we don't like ambivalence, we don't like questionable situations, we want to know is this person an emergency or not an emergency. Is this person for real or not for real? If it is an emergency, what sort of an emergency it is? And our brains work overtime to try to arrive at a conclusion ASAP. Now, ideally of course, you know we can be more may be like a computer program and say you know what may be there is a 60% chance that condition A is going on and may be there is like 25% chance that condition B is going on and may be there is condition C and condition D and let's keep all of these possibilities open and shift the percentages as we learn more about the case, but we don't work that way. Once we come up with a decision, like in this case, that the mother is a frequent flier, it starts to cloud everything else. It starts to dominate and it's very difficult to look at the data that's coming in and information that's coming as new and as something that can direct us. We hold on to that, and that first impression, that initial diagnosis, takes over.

DR. LESLIE LUNDT:

So we kind of get stuck on one track and we have a hard time seeing any evidence that doesn't meet that track.

DR. ROM BRAFMAN:

Exactly and you know as a psychologist I try to remind myself of that every time I see a client that immediately my brain says, you know, may be this is going on, may be that's going on and sometimes it's because of even little things, you know, may be the way the person is dressed or may be you know they didn’t comb their hair or may be they're not really talkative or may be the information that they give me, and I have stop myself and say am I really looking at all the different options or I am being stuck on one specific thing that's letting me astray and a lot of times, it's almost like an ego thing, like I don't want to think well I might be wrong and I can't afford to think I might be wrong all the time, but it's creating this perfect balance between being confident in where I want to go, but the same time being open to the possibility that I might be making a mistake and that's a really difficult balance to create.

DR. LESLIE LUNDT:

Now, Rom in the book you also bring up an issue that's near and dear, at least to me as a psychiatrist, and that's the so-called bipolar epidemic, tell us about that one.

DR. ROM BRAFMAN:

Oh, that's really interesting. You know, when I first went to school and took my first psychology class, and you know, we talked about all the different disorders and the professor talked about the bipolar disorder, and basically nobody in the class including myself knew what bipolar disorder was and the way they described it, he said, you know, it's a very rare disorder and it's a very extreme disorder when you have a person who just goes through these major extremes, being up like night after night after night and then on other nights when being so depressed you can't even get out of bed and you just oscillate back and forth and even showed us a picture of a man who was being arrested because he was walking in the middle of the freeway and he said that's the manic stage and it just stayed with me that bipolar is a very serious condition and bipolar is a condition that's also very rare and then during my graduate training I thought of hearing bipolar being used more and more often and it first goes like well, you know, some of it didn’t make sense because I thought bipolar was really rare and additionally bipolar started being applying to kids, teenagers, but even younger kids, so a kid who'd come in and they would be moody or the grades would go down or they would just come across to others as being a loner or being strange or being weird in some way and psychiatrists and psychologists started using the label of bipolar to describe those kids and there is a study that was done that between the mid 90s to a decade later, the bipolar numbers went up by a factor of 40 in the age group of kids which means for every kid that was diagnosed bipolar, 10 years later, you have 40 kids being diagnosed as bipolar and I talked about it with Ori and I said something is going on because we can't think of anything that might be going on to explain why so many kids would actually come up with the diagnosis of bipolar unless the disorder started being a catch phrase that unknowingly psychologists and psychiatrists started overusing the bipolar diagnosis and in my practice I see that all of time. I see mothers and fathers of teenaged kids come in and say I think my kid might have bipolar disorder and to me my first reaction is well if that's the case, then I want to take it very, very seriously because, you know, one of the things about bipolar disorder is that the chances of suicide behavior increases dramatically. So I want to be very sensitive to that, but if it's really a case of PTSD or if it's a case of mild depression, I don't want to use bipolar disorder just because their mood shifts from time to time.

If you're just joining us, you're listening to the Clinician's Roundtable on ReachMD XM 157, The Channel for Medical Professionals. I am Dr. Leslie Lundt, your host, and with me today we have Ori and Rom Brafman, the authors of "Sway." We are discussing the irresistible pull of irrational behavior.

DR. LESLIE LUNDT:

Now Ori, are the same psychological factors that work here with the bipolar “epidemic” as with the ER misdiagnosis.

ORI BRAFMAN:

Exactly, so what happens is that we tend to make a diagnosis based on the very little information and once we make that diagnosis, it's very difficult to see things in any other perspective, so after that initial diagnosis we ignore any data, no matter how strong that contradicts our initial diagnosis.

DR. LESLIE LUNDT:

That's all fine and good, but what about the hard part, how do we as clinicians resist this pull of irrational behavior?

ORI BRAFMAN:

Well, the thing is to really focus on data and there is an example we look at the book at job interviews and it turns out the job interviews and bipolar and the emergency room all have something in common and that's you have a person and situation where you need to make a diagnosis very quickly and the impact is going to be felt long after the initial diagnosis and it turns out that managers are actually really terrible at actually interviewing candidate and that job interviews are very poor predictors of actual performance on the eventual career, and the reason for that is that a candidate comes in, may be the say all the right things, they may be have something in common with them, we share a few jokes, say Oh, they're going to be great for the job, but there is a very local relation between those kind of job interviews and actual performance and the only approach of job interviews that actually works in the long run is asking pre-scripted questions and making sure that we focus on the relevant data, so rather asking what do you want to do in 5 years, ask questions like what specific qualifications do you have working in this job, what experience you have working on this offer. What would you do in this hypothetical scenario and that when we have the scripted job interview, we force ourselves to what Rom was talking about, look at the real data and not take the mental-psychological short-cut of arriving at a conclusion too early.

DR. LESLIE LUNDT:

So, I guess that clinical translation of that would be to use, say diagnostic algorithms in the ER where you asked the same questions every time for any particular presenting complaint, no matter what the mother's chart says or how they are dressed or whatever.

ORI BRAFMAN:

That's exactly what doctors are working on and what was interesting for me is in emergency rooms, I have talked to doctors where they said that a nurse might put something on the chart, just very casually, may be from initial interview and said oh this person might be suffering from heart disease or might be suffering from diabetes and even that little note in the chart, even if it's completely wrong, even if it was put there by accident, makes the doctors ignore other symptoms and often they see someone present with symptoms that they might not actually because they are so looking through to situation through the lenses of, well, here is a diabetic in front of me, let me ask them these questions or if someone who has heart disease let me ask them these questions and ignore data that contradicts what they think they are looking out.

DR. LESLIE LUNDT:

Well, thank you so much for being on our show today.

ORI BRAFMAN:

Thanks for having me.

DR. ROM BRAFMAN:

Thank you.

DR. LESLIE LUNDT:

We've been speaking with Ori and Rom Brafman about their book "Sway" which talks about the irresistible pull of irrational behavior and what you can do to stop it.

I am Dr. Leslie Lundt. You've been listening to ReachMD XM 157, The Channel for Medical Professionals.

For a complete program guide and downloadable pod casts, visit our website at www.reachmd.com. For comments and questions, give us a ring at 888-MD-XM157. Thank you for listening.

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