President's Message - Decisive

by Mike Fotis, ICHP President
February 3, 2014

What does decisive mean to you? Based on the title, you might assume this book is all about making quick decisions, but the purpose of Decisive is to describe “How to make better choices in life and work”.1 Decisive provides a lot of worthwhile advice, and Chip and Dan Heath do not spend a lot of time offering platitudes to solve real life problems. The platitude type of book offers nothing new and is usually a waste of time. You know…like a book with an entire chapter about the importance of good communication, which makes me think, “Oh you are saying good communication is important? No wonder I can’t get ahead. I thought bad communication was the way to solve problems!” You might have noticed this is one of my pet peeves!

Decisive served as the basis for discussion at the ICHP Leadership Retreat this past November. 

Some of the most useful suggestions are summarized below. I think this information can help to set up a framework to identify better personal and professional choices.
  • Search for alternative points of view
In clinical practice, one of the first things I check when selecting a review article for guidance is to see if the authors searched for alternative points of view and considered opposing findings in their search methods. After all, how useful would a clinical review be if the authors only considered articles that agreed with their point of view? We should remember to apply this method to decision making. We all need to protect our thinking from confirmation bias, and seeking opposite points of view is a good way to get a sense of how sound our thought process is. No need to follow the example set by politicians who seem to never be able to consider a different point of view. Rather, it is important to search just as hard for evidence that contradicts your point of view as it is for evidence that tends to support a point of view. 

  • Recognize uncertainty 
A good research paper describes their results by including 95% confidence intervals. We can adopt this thinking to non-clinical decision making. Many assumptions go into decision making. Taking a moment to consider your own confidence in each assumption can go a long way towards preventing poor decisions and act as a break against overconfidence. Don’t forget The Beatles were rejected by one recording label thinking that a 4 piece group was passÉ as everyone “knew” that popular music was moving exclusively to solo singers like Elvis. The Chicago Cubs decided against keeping Greg Maddux as everyone “knew” only power pitchers were capable of compiling a winning record.
  • Narrow framing
It is so easy to fall into the trap of narrow framing. We do this every time we decide based on a whether or not statement. If there are only two choices to decide from, most likely the decision is based upon narrow framing. Of course we can have too many choices and end up with paralysis by analysis. However, whenever we are faced with binary options, it’s time to think about a third and possibly a fourth choice before making a decision. Thinking outside of the box is all about considering more than the stated options. For example: Should you keep your job, or should you leave and do a PGY1 residency? If you like the job you have right now maybe a third option is to approach your boss about setting up a non-traditional residency? Not possible? Perhaps your boss would be willing to help you to gain residency equivalent experiences? Why you might even present your project at an ICHP meeting! I am not suggesting one of these is THE RIGHT ANSWER for you, but instead I’m suggesting that you avoid only binary choices and consider one or two additional alternatives. Another way to avoid narrow framing is to consider “vanishing options”. What would you do if you COULDN’T choose one of the binary choices?

  • Consider opportunity costs
Opportunity costs include time as well as money. What else could you do with your savings if you didn’t purchase an expensive investment? What else could you accomplish if an unnecessary workload function was identified and eliminated? Tech-Check-Tech comes to mind as an example. A second example: Many pharmacy departments are assigning entry-level departmental responsibilities to experiential students instead of to pharmacists. In addition to reducing opportunity costs, pharmacists are performing other duties while the students take over, and these departments have avoided the binary choice, “Should we have our pharmacists do this duty or not?”

  • Consider the risk and cost of inaction 
Some problems require a bold decision. Success may be difficult to achieve. Before deciding to delay or even to table an idea, spend a few minutes considering the impact of a likely outcome if we fail to act. Often we forget that taking no action is still a decision.

  • Gain distance to minimize emotions
Decisions affect family members, colleagues, and patients. A lot of emotions come into play. The authors offer a number of suggestions to help to gain distance. Think of these suggestions as a method to gain distance. These suggestions are not implying that you ignore concerns of family, colleagues, etc.  
    • Professional decisions: What would you decide if you were brand new to the organization?
    • Personal decisions: If a close friend was facing the same choices, what would you advise? 
    • All types: Use a 10-10-10 strategy. What would you think about the problem in 10 minutes, 10 days and in 10 years?

  • Test assumptions
What else would have to be true for choice A to be the best option? For Choice B and Choice C? What is your confidence in these assumptions? One technique I used often at the P&T Committee was to ask an overzealous advocate for a new drug, “If this new drug is so good, why can’t we take the old drug off the formulary?”
  • Honor your core priorities
What kind of person (parent, spouse, coworker, teacher, clinician) do you want to be? What is your purpose? Please don’t allow a “B” priority to interfere with “A” level priorities. The authors used an example faced by volunteer agencies. Their question (note the narrow framing): “On mission trips should volunteer clinicians be allowed to bring along their families during surgery?” Your decision is “yes” if satisfying the volunteers is your purpose, but the answer is “no” if safe surgery is your purpose. We should also change the whether or not statement to include other options for family.

Of course as a leader you can’t make everyone happy. BUT you can conduct a decision making process that insures that everyone is heard, that core priorities are recognized, and that important and creative options are considered. Using a process that all parties recognize as fair builds your strength as a leader. How a leader makes decisions goes a long way toward building a successful team. 

Heath C, Heath D.  Decisive: How to Make Better Choices in Life and Work.  New York: Crown Business; 2013. 

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