“Stay committed to your decisions, but stay flexible in your approach.” — Tony Robbins

The ability to make difficult decisions is the mark of an effective physician.

While decisions in medicine can be difficult for a number of reasons, ways to manage many of these challenges are readily available.

If the difficulty lies in defining the goals of treatment, we can solve this by spending more time listening and talking to our patients. If the difficulty is lack of comfort in managing a particular situation, we can become more literate with online resources to access information and converse with other physicians. If the problem is our own cognitive biases or decision fatigue, becoming aware of these errors in thinking can minimize their effect.

Despite ways to manage many of these challenges, certain decisions in medicine are inherently going to remain extremely difficult.

Features of extremely difficult decisions in medicine:

• An incorrect decision has a high risk of adverse consequences.
• Limited information is available to make the decision.

Of these two features, we typically have no way to control the amount of risk involved in our decision. We might also feel that we have no control over having limited information, but this is incorrect.

We are actually able to manage information limitations in medicine.

The 40-70 Rule in Decision Making

Former U.S Secretary of State and General Colin Powell is known for the 40-70 rule in decision making, stating that a leader should make a decision when they have between 40% and 70% of the information available.

”If they make the decision with less than 40% of the information, they are shooting from the hip. But waiting for more than 70% of the information delays the decision unnecessarily.”

Applying this to medical decision making:

• By the time you have gathered 40% of necessary information, a skilled clinician should have narrowed diagnostic and treatment possibilities enough to make an effective decision.
• By waiting for more than 70% of information to become available, we may actually increase risk by delaying a decision.

The surprising part here is that by delaying our decision beyond a certain amount of information, we may end up with worse outcomes.