Intuitive and algorithmic decision making and The Simpsons

One of the most popular Simpsons episodes ever – MoneyBART – succinctly describes the struggle between intuitive and algorithmic decision making in physical therapy.

This struggle, catapulted to prominence in 2002 with the publication of Flynn’s manipulation rule, is not unique to physical therapists.

Physicians, too, resist the influence of decision rules and adhere poorly to clinical practice guidelines.

Physical therapists share some commonalities with physicians in that we overestimate our ability to access medical knowledge relevant to the patient, to screen for low-frequency events and to apply effective treatments while mitigating the use of ineffective treatments.

MoneyBART captures what I think is one of the drivers for the low utilization of evidence-based decision rules (including treatment-based classification). This driver is captured in the struggle between Lisa and Bart.

Lisa argues for numbers and statistics – the “brains” of the algorithmic, “computer logic” behind treatment based classification – while Bart argues for his “gut” – the intuitive, naturalistic basis for pattern matching traditionally employed by physical therapists.

In the episode, Lisa becomes the manager of Bart’s Little League baseball team even though she doesn’t know anything about baseball (“Go kick a field goal, Bart!”).

To learn about baseball, Lisa turns to a team of statisticians who meet to discuss sabermetrics at Moe’s Tavern. Using this brand of statistical baseball analysis, Lisa begins winning games and Bart complains that she has taken the fun out of the game. Bart gets kicked off the team after disobeying Lisa’s instructions to walk off a pitch and hits a home run, winning the game.

Lisa eventually makes the city championship and she asks Bart to come back because she needs Bart to pinch run from first base. He agrees to help but again disobeys her management and tries to steal all the way home. As Bart makes his move, Lisa calculates the odds as being vastly against him but, instead of being mad, comes to love the thrill and excitement of the game. Bart is tagged out at home, losing the game and the championship, but Lisa thanks him for showing her how to love baseball as a game.

In fairness, I’ve made some simplifying assumptions that physicians and physical therapists resist clinical decision support (CDS) because of personal factors (“It takes the fun out of the game”) when, in fact, clinicians are professionals who may resist the “top-down” management of complex doctor-patient interactions they perceive as limiting.

Physicians typically not trained, incented or supported for using evidence-based decision rules. The rational response, then, is not to use them.

But, we do have good evidence that safety and efficiency, from high-quality impact studies, are both improved when algorithmic decision making replaces intuition.

Does that take the “fun” out of the game?

Medicine isn’t Little League so, if we’re going to play, let’s play to win.

Tim Richardson is a physical therapist who blogs at
Physical Therapy Diagnosis.

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  • family doc

    Your assumption that physicians resist clinical decision support for personal reasons is incorrect.

    “Physicians typically not trained, incented or supported for using evidence-based decision rules.”

    Nonsense. We were trained on evidence-based decision making 15 years ago. We have some incentives of debatable value in place for years. Administrators are supportive of putting guidelines into use in many areas.

    The problem is that clinical medicine is not a simple as the poster assumes. Few patients just have diabetes, or just CHF or only COPD. Virtually all of my patients have a mix of these illnesses, many have 3 or more. This leaves us with clinical decision support guidelines that conflict. Add some drug allergies , drug interactions, and personal, social or cultural issues and it shouldn’t be surprising why we appropriately vary from the guidelines. None of this requires personal reasons.

    Your analogy to sabermetrics is too broad. The useful measures in baseball sabermetrics are almost all offensive stats because those events can be measured in isolation. Sabermetrics is much less useful at evaluating defense where multiple factors come into play simultaneously. Unfortunately,that is the more common scenario in clinical medicine.

    • http://thedocsquawk.com thedocsquawk

      Agreed. If medicine was as easy as following a flow chart, nobody would need a doctor. One of the important things a doctor does is decide when guidelines apply and when they don’t. I would hope the majority of times MDs deviate from guidelines have been for good reasons, rather than ignorance.

      • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

        Agreed.

        A CDS system that requests clinicians provide documentation of their reasons for deviating from guidelines is associated with improved clinical processes 100% of the time.

        Without this feature, the CDS is associated with improved clinical processes only 59% of the time.

        Tim

      • http://www.PhysicalTherapyDiagnosis.com Tim Richardson

        Sorry,

        I should have included the reference:
        Kawamoto et al. 2005
        BMJ; doi:10.1136/bmj.38398.500764.8f

        Tim

  • gzuckier

    This touches on a huge issue. Currently widely accepted personality theory suggests that people may be generally divided into “thinkers” who are explicitly data-driven, and “feelers” who operate on their “gut instinct”; and that it is enormously difficult for these two groups to understand each other’s point of view, trust each other, work together, etc. In reality, of course, neither methodology is absolutely preferable; it depends on both the situation and the competence of the individual’s brain/gut. But one merely needs to look at the publicly expressed attitudes towards the current and previous US presidencies and the great split in American politics currently to see the truth of this basic antipathy. Unfortunately, far from suggesting how to ameliorate this group dysfunction, the aforementioned personality theory is pretty pessissimistic about the chances of ever doing so.