Combining emotion and reason in decision making

We are living in unprecedented times. Times filled with emotion and very little hard science. We are faced with the rapid spread of a new disease that has devastating consequences. The rapid spread is overwhelming our system that is designed for a steady state. Periodically, we are faced with events that overwhelm our system; mass shootings are a prime example. The duration of those events is measured in hours. We are currently faced with an event that will be measured in weeks and months. The illness is particularly devastating to physicians because of a lack of treatment and sporadic failure of it to respond as expected to supportive care. Mix into that the uncertainty surrounding how the disease is spread. We have not experienced an event with this much uncertainty and emotion in our lifetimes.

All physicians are leaders. We are leaders of the care team at the bedside. Many are leaders within our groups, hospitals, and other organizations. As leaders faced with uncertainty and emotion, we are called upon to make good decisions even in times like these. Especially in times like these. We make decisions and form opinions based on what we know or can infer (rational) and what we feel (emotion), a process called affective decision making (ADM) – not effective, though affective decisions are likely to be the most effective. Many of you are familiar with the concept of thinking fast and thinking slow by Daniel Kahneman. As clinicians, much of what we do is “thinking fast,” and we must force ourselves to “think slow” as a means of supporting our “thinking fast” conclusion. Affective decision making is a “thinking slow” process that is very difficult. To make affective decisions, we must be able to recognize emotions in our self and understand that emotions are influencing our opinions and decisions. We must balance this with the rational influences on our decisions.

Fans of the show Star Trek will recall that Spock made all his decisions based on reason as he was devoid of emotion. Fans also will recall that Kirk usually made better decisions because he recognized and allowed emotions to influence but not dominate his decision making. It is crucial during these times that physicians form opinions and make decisions based on a balance of the rational and the emotional.

ADM is especially difficult because of the imbalance between emotion and rationality we are experiencing daily. There is not much universally accepted science to help us form the rational portion of our decision making. However, our education has trained us as scientists and thinkers. Faced with uncertainty about a disease process, we are uniquely trained to fall back upon our knowledge of physiology, biochemistry, pathology, and the like to help us form our rational approach. Physicians are the only members of the team that are trained to do this. We must embrace this and lead the way.

Just as we are hamstrung by the dearth of evidence upon which we can form the rational portion of decision making and opinion forming, we are hampered in dealing with the emotional aspect. One of the techniques leaders use to allow emotions to guide but not unduly influence the formation of opinions and decisions is to manage those emotions. People manage emotions in individual and varied ways. Talking about and expressing those emotions is frequently present in many of those techniques. This is especially hard in this time of physical distancing as we are not able to gather together and express those emotions and sympathize with one another. We want to be a calming influence on our families and friends that we dearly love so often don’t even turn to them to let our emotions out. When emotions remain pent up inside, they more likely to unduly influence our decision making. Physician leaders must recognize this and find ways to manage our emotions or at least realize they may be having an undue influence in our decision making.

Affective decision making is crucial for each and every physician to understand and practice and never more so than during this journey through COVID-19. Engage in “thinking slow.” We need to take time to wrestle with both the emotional and rational aspects of the opinions we form and the decisions we make every day. Consider the idea that opinions formed with undue influence of emotion should not be shared widely on social media as it may serve only to fuel the emotion rather than foster productive dialogue. Our ability to make excellent affective decisions is crucial and will cause us to be viewed not only as “heroes” but as leaders.

Robert Frolichstein is an emergency medicine physician.

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