How Do You Decide?

By Kelly Sanders, PT, DPT, OCS, ATC

We make decisions in and for our practices every day, but what guides us in making them? Many people tend to think of a decision as a momentary occurrence rather than a process. Considering decision making is a process, one of the key aspects of this process is how a decision is made versus what decision is made. I have come to realize that as a clinician, I make decisions differently than I do as a business owner. As clinicians we are taught to constantly challenge our decision-making process. For example, as a physical therapist, we commonly look at an “asterisk sign” for a patient, then complete our intervention, then go back and re-test that asterisk sign. If the asterisk is improved with our intervention, we continue along that path of thought; if that asterisk sign did not improve with the chosen intervention, we ask ourselves was this the wrong intervention or did we complete the intervention incorrectly? In essence, we follow a test-retest approach to clinical intervention decisions. For the purposes of management, we will suggest a framework for decision making but the test-retest style will commonly fail. Management is truly the art of managing the “gray areas.” Many decisions will not be as black and white as the asterisk sign, they will be vague, which will require you to “make the call” and then in many cases commit to that decision to obtain buy-in from others.

Regardless of your position or title, those willing decision-makers (or those able to ask the right questions to facilitate the decision and stand by them) generally stand out as the leaders.

Here is one rendition of the decision-making process in its entirety.¹

1. Identify the problem and/or articulate the question that must be answered to start the decision-making process. Commonly, the root of the problem is buried under many “symptoms.” These symptoms will alert you to an issue but will not assist in addressing the root of the problem.

2. Before alternatives are identified, take note of what resources you have available to solve the problem and what potential limiting factors may exist. These may include information, time, staff, and supplies. In reality, you are not always confronted with situations where you have the best scenario in terms of resources available—maybe you have a limited budget or staff. Regardless, you need to define the resources you do have and make the best decision given the information, resources, and time available to you.

3. In order to think through a situation and arrive at a firm solution, identify and investigate your alternatives. Depending on the situation, you may decide to involve a group to brainstorm and capture feedback, generate multiple ideas and solutions.

4. Evaluate each of your alternatives. There are many ways to do this but one way can be evaluating based on a pro/con list or cost/benefit analysis. Regardless of how you evaluate your alternatives, you want to look at the feasibility, effectiveness, and consequences of the decision.

5. This step in the process is where the results come in. In decision-making, you are not only charged with making the decision but also executing it. Those affected by this decision need to be told their role in it to ensure a positive outcome.

6. Once a decision is made and implemented it should be monitored. Ultimately, every decision is intended to solve a problem. So the final test is whether that problem was solved. Did this decision achieve the necessary/wanted result? What new problems did the solution create, if any? This is the step similar to the clinical decision process—when we reassess the asterisk. If the issue was not effectively solved with the decision, consider these questions:

1. Was the wrong alternative selected?
2. Was the correct alternative selected but improperly implemented?
3. Was the original problem identified correctly?
4. Has the implemented plan been given enough time to succeed?

As you go through the process of making decisions, keep these pitfalls in the back of your mind. As humans we tend to make some common mistakes when making decisions, known as cognitive biases. These biases exist because decisions are social, emotional, and oftentimes political processes which affect all of us regardless of experience, age, or position. We cannot review and assess every contributing factor when making decisions so we naturally take shortcuts and make assumptions but in some cases, these shortcuts lead to poor outcomes and decisions. Here are a few of the many biases in decision making to be mindful of:²

• The overconfidence bias. As human beings we are systematically overconfident in our judgments, which can obviously affect our decisions.
• The sunk-cost effect. The sunk-cost effect refers to the tendency for people to overcommit to a proposed solution in which they have made substantial prior investments of time, money, or other resources. In the face of high sunk costs, people can behave irrationally and become overly committed to certain actions even if the results are bad. We have all heard the term “throwing good money after bad,” which illustrates this bias.
• The recency effect. The recency effect is one form of the “availability bias.” In this scenario, we tend to place too much emphasis on information or evidence that is most readily available to us.
• The confirmation bias. This bias refers to our tendency to gather and rely on information that confirms our existing views and to discount information that disconfirms our preexisting hypotheses.

A good video course is available from Dr. Michael Roberts titled The Art of Critical Decision Making from the Teaching Company. It provides an excellent overview of decision making with multiple examples of where decision making went awry.

Bottom line, think through your decisions and be aware of your own biases. In important decisions, identify confidantes who are aware of your biases and will challenge and work through the steps of the decision thoughtfully with you.

Resources

1. Snowden J and Boone M. A Leader’s Framework for Decision Making. Harvard Business Review. November 2007.http://hbr.org/2007/11/a-leaders-framework-for-decision-making/ar/pr. Accessed 2/25/2012.

2. Raxburgh C. Hidden Flaws in Strategy. McKinsey Quarterly. May 2003. www.mckinseyquarterly.com/article_print.aspx?L2=21&L3=37&ar=1288. Accessed 7/30/2012.

Kelly Sanders, PT, DPT, OCS, ATC is a member of the Impact editorial board. She also serves as president of Team Movement for Life, a 19-location outpatient physical therapy practice operating in California and Arizona. Kelly can be reached at kelly@movementforlife.com.