Decision Science Roles in Medical Decision Making

Medical decisions are difficult for several reasons:

·         They involve multiple objectives, such as alleviating pain and suffering, quality of life, long term health impacts, cost, and so on.  

·         They involve numerous participants:  the patient, doctors, insurance companies, family, employers, and yes, even the government.  

·         More and more data (both good and not so good), is becoming available.  What information is more reliable and what treatments do the more reliable information support?

The question of who makes a medical decision is paramount.  Ideally, for most of us, it would be the patient, and ideally it would be a decision to select that alternative which best satisfies the patients objectives.  (A decreasing minority of people would like nothing to do making with the decision but just leave it up to the doctor).  Determining which alternative is ‘best’ is usually difficult because it requires a synthesis of tradeoffs among conflicting objectives, interpretation of opinions of more than one physician, and an understanding of the complex and often competing data and research results. 

Common practice today consists of a series of medical examinations, tests, and consultations, followed by a haphazard search for additional information.  The patient is often left weighing pros and cons that result from physician recommendations that are: conflicting, biased (naturally so since each understands their specialty best) , and constrained by cost/insurance considerations.  The patient must make a gut feeling choice after sleeping on an overload of information.  Moreover, the decision alternatives may be limited to a set of alternatives that have been pared down because of what some bureaucrat (does it matter if the bureaucrat works at an insurance company or the government?) has decided.

Newer techniques for helping patients decide are evolving.  These typically involve a more systematic way of gather information and presenting it to the patient (see “Weighty Choices, in Patients’ Hands”, Wall Street Journal, Aug 4, 2009 <http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html>.  

However, even if the patient has the latest and best information, the decision is not likely to be one that best meets the patients objectives for at least two reasons.

First, and perhaps at the center of today’s debate on health care, is that patient  alternative choices need to be broadened by reducing restrictions imposed by insurance companies, government, and the ability to pay.  Vested interests are making it difficult to change from what is obviously a poorly functioning system where a patient is rarely even aware of the cost of alternative treatments, and  is sometimes even prevented from choosing  specific alternatives  which are deemed inappropriate by a third party.   Decision science has much too offer in this debate, but has contributed little thus far.

Second, in order for patients to make decisions that best meet their objectives, they must be able to synthesize data and information (much of which is very technical), physician opinions (sometimes from physicians in different fields, each only superciliously knowledgeable about fields outside their own), and most importantly, their own objectives (which are often conflicting).  

Medical decisions, are, by their very nature, subjective.  This is because the relative importance of the patients objectives differ from patient to patient.  But subjective doesn’t mean casual, sloppy, or inconsequential . Subjective simply means that the decision will differ from patient to patient.  There is, in fact, a single best choice for each patient.  Theoretically sound and practical techniques in the decision sciences, such as the Analytic Hierarchy Process,  have been shown to be able to help patients determine the alternative treatment best suited to their individual circumstances and objectives. (A Novel Computer Based Expert Decision-Making Model for Prostate Cancer Disease Management”, Journal of Urology 2005 Dec; 174(6) 2310-2318) http://linkinghub.elsevier.com/retrieve/pii/S0022534705009626.  Not only can such techniques help patients make decisions that best meet their objectives,  reassure patients that they are making the ‘best’ decision for them, are convincing to attending professionals and third parties who may be footing part or all of the bill, but the decisions can actually be less costly to the patient, insurance companies and the government alike.  The use of such techniques is likely to become widespread in the not to distant future.

Eileen Federic wrote an interesting article in Baseline which addresses “getting the right information” for a decision. There are many important ideas in this article, and no one will argue that getting the ‘right’ information is necessary, but it is not necessarily the ‘key’ to making the best decision. In today’s world, we often have more information than we can process effectively, especially when it comes to ‘crucial’ decisions that can result in the success or failure of a project or business.

Just as important as having ‘good’ information, and sometimes more important, is the ability to synthesize the information to make a decision. This is no easy task, given that all important decisions have multiple, conflicting objectives, and most important decisions have multiple decision makers who, if left to their proverbial ‘gut feel’, as you put it, would not necessarily come to the same conclusion. Hence, arguments, hurt feelings and loss of time are too common.

The decision on how much time and money to allocate to gathering information is in itself an important decision. But no matter how much time and money are allocated for this purpose, there will always be some missing or ‘untrusted’ information in any important decision. The quality or veracity of information that is at hand, as well as uncertainty and risk due to incomplete information must all be taken into account. Eileen recognizes that there is much more than getting the ‘right’ information, when, at the end of her article, she observes that “Clearly, facts are the foundation of the decision-making process, but facts without an analysis and understanding of consequences aren’t enough to achieve hoped-for results. We need a convergence of accurate information, the right technology and processes to analyze that information and provide business insight”.  However, analysis, (meaning to break things down) is only part of the process. Because all important decisions are multi-objective, synthesizing the parts into a whole is even more of a challenge and needs to be addressed in any effective decision process. This synthesis must include not only factual data; intuition and subjective judgment must play a key role in interpreting the data and synthesizing the information.

There are several decision process that have been developed over the last half century or so that address the difficulties and approaches to making important, multi-objective, decisions. One such process that is both theoretically sound and which has been effectively applied to thousands of decisions is call the Analytic Hierarchy Process (AHP). I have been teaching AHP at The George Washington University School of Business for more than 25 years and it is now being taught at many of the leading Universities in the United States as well as abroad using software I developed with Expert Choice.

Ernest Forman
Professor of Decision Science
The George Washington University

The Financial Redress

Three score and four years ago our fathers brought forth upon this earthen sphere, a new order conceived in economic liberty, and dedicated to the proposition that all trade is created equal.

Now we are engaged in a great idea war, testing whether trade, or any human interaction so conceived and so dedicated, can long endure. We are met on a great trading floor of that war. We have come to dedicate a portion of our future income, as a resting place for those banks who here gave their shares that financial markets might live. It is altogether fitting and proper that we should do this.

But in a larger sense, we cannot dedicate – we cannot consecrate – we cannot hallow – liberal trade. The brave institutions, past and present, who traded here, have consecrated it, far above our poor power to add or detract. The world will little note, nor long remember what we say here, but it can never forget what they did here. It is for us, the remaining, rather to be dedicated here to the unfinished work which they who fought here have thus far so nobly advanced.

It is rather for us to be here dedicated to the great task remaining before us, that from these failed institutions we take increased devotion to that cause for which they gave the last full measure of devotion; that we here highly resolve that these liberal efforts shall not have died in vain; that this world under God, shall have a new birth of freedom, and that this world order of the people, by the people, and for the people shall not perish from this earth.

When the going get’s tough, the tough have some choices to make.  There are some schools of thought here.  The first is that this is a golden opportunity for most companies to lay off the unproductive bottom 10% of their staff.  A second is to reduce future revenue generating efforts (such as new product development projects).  A third is to ask for an across the board reduction in exempt staff salaries.  A fourth is to reduce bonuses to an absolute minimum (especially since most staff will not quit their jobs with the economy as it is).  A fifth is to shift support staff to sales efforts (hence reducing the non-productive time of sales people).  A sixth is to ask for graduated reductions in pay (those with highest salaries receiving a greater share of the cuts).  A seventh is to slash prices on all items that don’t move, while reducing prices on hot sellers less.  An eight idea I heard was to offer all customers an iPhone with their purchases, since that seems to be the only thing that’s still selling like hot-cakes.

But whatever you choose to do, how will you make the decision?  Alone with a bottle of Jack?  With Jack, and a bottle of Perrier?  Or with Jack and Pierre and Otto and Lakysha and Anil and Sergey and Wang?   Today’s companies operate in 24 time zones (or 24 home offices in one city), have wastly different local customs, regulations, and success levels.  What’s perfect for New York may not work in Tokyo, and what’s right in Berlin can seem foolish in Cape Town.

Here’s an outline of process we are using to help our customers:

Part I – And the problem is…
You have to define the problem before you plan a solution.  Too many companies attempt to make changes to their plans without defining what has changed and how the new plan should address this.

Part II — …we need a process…
You can go without a process… you just won’t be very successful.  Circles are nice for doodling.  But don’t get caught going in circles when times are tough.  Without a process, you are walking with one leg a foot shorter — and will tend to circle the room.

Part III — …that we can buy into…
So you have a process.  Great.  Does anyone buy into it?  If your process is opague and non-inclusive, no one will buy into the results.  Open it up to the relevant people and set expectations for how their input will be used.  Just because people participate, the have to know that companies are not democracies — but why not let them bring good ideas into the mix?

Part IV – … and communicate to the organization
Once the leaders decide on what to do, they have to find a way to have the followers follow.  You have your carrots and your sticks, of course.  But usually there are not a lot of carrots in a recession, so that leaves sticks…  Not a good way to have people follow leadership.  So find new carrots that don’t cost money.  Communicate, provide non-financial benefits, give stock in lieu of cash bonuses.  But whatever you do — just make sure you communicate your sincere intent (unless of course your intent it’s insincere, in which case you are unlikely to be reading this.)

So, that’s the process.  Now get going.

By the way, I make software that helps with this.  www.expertchoice.com.

Good outcomes are the result of three factors: Quality of the decision, quality of the execution, and chance.    Quality of a decision comes down to a correct assessment of the ability to execute and the element of chance (which includes risk).  Quality of execution similarly is strongly related to chance, as executing without regard to risk is foolish.

Over the past decade or two the world’s business leaders have been obsessed with execution.  Here is a typical list from Amazon that shows a strong focus on execution as strategy. A similar list of books on risk is telling.  The focus here is more tactical and technical.  Risk apparently is the domain of geeks, not general managers.

And who was focusing on decision making?  Again a simplistic list from an Amazon search is revealing: almost all the books are on the psychology of individual decision making.  Few titles on collaborative decision making, or improving businesses to make better decisions. Put simply: why has there been so little focus on decision making that marries execution and chance for better business outcomes.

The current economic crisis is immensely complex and flip summaries will not resolve it.  However, it is clear that decision making in business, government oversight, and personal behavior has been found wanting.

- A finely tuned system that executes well, when all is well, will not do in dire times — our banking system is Exhibit A.
- Risk models that model economic times when there was little risk, will not tell us about the dangers the future inevitably holds– our housing and mortgage industries are Exhibit B.
- Business leaders whose rewards are reaped in the short term, will not make good decisions for shareholders and households that plan to reap their rewards in the long-term– our current stock markets are Exhibit C.
- Government that aims to regulate the interest of all market participants while clearly sitting in the pocket of some stakeholders earns the trust of no one– our crisis of confidence now is Exhibit D.
- People who have become only consumers, and whose life-style is borrowed with abandon, one day will have to return to the values of that People–we are almost all, unfortunately, Exhibit E.

Decisions.  We all face decisions.  Hopefully next time they will be better–decisions that acknowledge the importance of risk, and decisions that take into account our ability to execute.

We’ve created a new site, OlympicDecision, to highlight the current International Olympic Committee process around choosing a host city for the 2016 Summer Olympics. The finalists are Chicago, Tokyo, Rio de Janeiro, and Madrid. We built a collaborative decision exercise for the community to help determine what criteria should matter as well as evaluating each city against the criteria. Check it out!

From turning down the Beatles to failing to recognize Microsoft’s potential, there have been some seriously bad decisions made in the business world. Neatorama has reprinted The Stupidest Business Decisions in History.

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Some people made decisions that led to the world best discoveries while others thought we couldn’t “drill into the ground to find oil”. “Bad Quotes for Famous People” (courtesy of The Univerisity of Western Ontario) demonstrates how ingrained biases can lead to a failure to recognize potential.

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People make decisions and very often second guess themselves. Here is an article from The Huffington Post on “How To Be Satified With Your Decisions“.

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“When you have to make a choice and don’t make it, that is in itself a choice.”  ~William James

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“The hardest thing to learn in life is which bridge to cross and which to burn.”  ~David Russell

Washington DC’s favorite quadrennial parlor game is underway. Who will Sens. Barack Obama and John McCain choose as their running mates?

While the needs of Obama and McCain are vastly different, the structure of their decisions are essentially the same. Each needs to weigh a range of criteria, including experience, the ability to attract constituencies, and things like age and various intangibles.

I’ve constructed a model to help each determine what really matters when choosing the right running mate, and I need your input. This isn’t an exercise to identify the best candidate, but to determine the criteria they should use when evaluating the candidates (I can add in candidate evaluations, so let me know if you’re interested in blowing this out).

This process helps eliminate the biases and personal preferences that can corrupt the decision-making process. I also feel that with these results, the right candidates will become self evident.

I’ve utilized Expert Choice’s Comparion platform for this exercise. It’s typically employed for collaborative decision-making in organizations, and I’ve had to do a little re-engineering for our purposes here.

It takes about five minutes to do, and I think you’ll find it interesting and hopefully a little enlightening. I wish I could automatically update the results here on the blog…but I’ll be updating them here daily.

Click Here to Participate in the Survey

Click the two images below to view the preliminary collaborative results. Some interesting results so far…

- Much more emphasis is placed on the need for “Experience” regarding Obama’s Veep than McCain’s.

- McCain needs to focus more on a Veep that can attract the conservative base than Obama needs to worry about the liberal base.

- McCain needs someone that has business/management/economics experience, but people don’t think Obama needs the same. That said, Obama may need someone with foreign affairs experience.

- McCain may need to worry more about picking someone with negative baggage.

- Both candidates shouldn’t ignore the need for their running mate to help carry a specific state or region.

I’ve pasted the model for Obama and McCain below. Note that I’ve kept it rather simple for the sake of time and having fun with it. I’m open to suggestions or criticisms.

Sen. Obama
Experience (primary criteria)

- Brings foreign affairs and/or military experience to the ticket (sub criteria)
- Brings business, management, or economic experience to the ticket
- Brings political and/or policy achievement to the ticket

Constituencies
- Attractive to the liberal base
- Attractive to the women vote
- Attractive to the middle class
- Can help carry a swing state or region

Intangibles
- Age (brings balance to the ticket)
- Gets along with Obama / a team player
- Lack of negative baggage

Sen. McCain

Experience (primary criteria)

- Brings foreign affairs and/or military experience to the ticket (sub criteria)
- Brings business, management, or economic experience to the ticket
- Brings political and/or policy achievement to the ticket

Constituencies
- Attractive to the conservative base
- Attractive to the women vote
- Attractive to the middle class
- Can help carry a swing state or region

Intangibles
- Age (brings balance to the ticket)
- Gets along with McCain / a team player
- Lack of negative baggage

The Deciders…

Tolstoy begins Anna Karenina with a flawless blog-entry:  “Happy families are all alike; every unhappy family is unhappy in its own way.” Admittedly he loses his blogging style a little as he goes on for about 700 pages explaining his point.

But there’s more to this epanalepsis than witless wit.   Could it be that our choices and decisions fall into a similar logical structure?  Put differently, is it true that “All good decisions are alike; each bad decision bad in it’s own way.”

In the most simplistic sense this is true.  All decisions that help us achieve our goals are good in that they achieve their end — decision that fail, fail for any of a number of reasons, with luck and execution often playing a prominent role.  It seems very dissatisfying, however, to qualify decisions based on their outcomes.  We all have made a good decision, one that we felt was the right one, only to never see the wished for result .  This is because for all non-trivial decisions there is some uncertainty about the outcome.

The true question is if we can describe a universal optimal decision making procedure that would apply for all decisions where the outcome is uncertain.  Ironically, the quality of a decisions cannot be measured by the outcome at all.  Since we do not know the outcome at the point we make a decision, it is outside of the scope of the analysis.  What we rely on instead is the much less concrete notion of ‘expected outcome.’  The sad secret is that people are rather poorer judges of what will actually happen, than they think.  In short, we are overconfident about our ability to predict the future.

So, what is the universal decision making procedure?  I’ll leave that answer for a non-blog dissertation, but instead offer some observations.  Before you make a non-trivial decision you need to know some things.  Below are some of the things that I look at — I don’t always look at them in a particular order, and some I may look at more than once:

• * When is the earliest/last moment I can make this decision? 
• * What would be true of the outcome that I desire?
• * What are the factors that are relevant in that outcome and how important are they?
• * When examining alternative solutions, how will I select among them?
• * What information do I not have that is important to have — who could help me get it?
• * What evidence disconfirms where I’m leaning?
• * Can I reverse this decision once made?
• * What assumptions about the future am I making in my deliberations?
• * Should someone else (e.g., boss or a direct report) be making this decision?
• * Does how I make this decision matter in getting the results that I seek (i.e., do I need to involve other’s to get their buy-in, understanding, assistance)?
• * Is there a legal, ethical, or moral dimension to this decision that I should consider?

This may seem like a lot of steps, but for a small decision I can cycle through them in a few minutes, or even seconds.  For an important decision it may take longer.  These questions are never superfluous, however.  If the decision is important, making explicit (even if only to yourself) your choice, instead of keeping entirely intuitive is valuable.  If you need input from others it is critical.  If you are making a decision outside of your experience/expertise it is the only way you can really properly make the decision.

Cooperation and collaboration may rival computers and communications technology as the most improved aspects of business in the past 50 years.   Optimists hope that management by fiat, grunts, and growls will sometime soon be fully replaced by a conscious attempt to arrive at the best solution, regardless of its source.  This, I’m afraid is folly.  Two major problems remain to be solved before we herald in the era of kumbayaesque business practices:

1. The transaction cost of keeping everyone happy, and
2. The elimination of poutology as a career strategy.

Let’s treat them in turn. 

Transaction costs is a technical term from economics.  In it’s simplest form this can be thought of as just what it costs to exchange things in a market place.  More generally, transaction costs can be seen as the direct and indirect costs of obtaining a certain outcome.  So, in a business decision environment we can view transaction costs as the price of paying off the foot-draggers, saboteurs, whiners, and single-focus freaks.   In a highly collaborative environment where consensus and collaboration are valued as an end in themselves (because they are believed to bring about better decision options and execution actions) this cost is not negligible.  Who hasn’t seen a decision delayed, implementation altered, or lowest-common-denominator choices prevail, because someone appeared to object.  This is especially prevalent in hiring decisions, where a single ‘uhmm’ can be seen as the prelude to a veto war. 

Poutological behavior is more pernicious.  While more common among friends and family, pouting is often employed effectively as means to an end in business.   This refers to the act of pouting to gain leverage later.  In a sense, this is a particular type of anchoring bias.  If I pout about a decision today, but then acquiesce ‘because I’m a team-player’ then next time people will, whether they realize it or not, take into account my “magnanimous” gesture.  The net effect is that the pouter has greater leverage coming into the next round of collaborative decision making.   A pouter who is perceived as being invaluable has double leverage since the implicit threat of abrupt departure hangs over the team like Damocles’s sword.

Tomorrows collaboration tools and team training in business school have to do more than just help us collaborate and achieve consensus.  Managing the process of collaborating, disarming the poutologists, and reducing transaction costs are very important to help us avoid the politics of teams, and the dreaded ‘groupthink’ which poorly configured teams often sink to.  Such tools will allow us to prioritise tasks, and maintain a goal-oriented focus, thereby making politically motivated pouting as transparent as a child’s crossed arms and foot-stomping.