Of puzzles and mysteries – thoughts Malcolm Gladwell stimulated

23 Oct
2007

Yesterday at the SMDM (Society of Medical Decision Making) meetings, Malcolm Gladwell spoke. I had the opportunity to meet him after his talk. I can report that he was very interesting as a speaker, and very pleasant to meet at the reception.

He talked about decision making in general. He proposed this distinction between puzzles and mysteries – puzzles require collecting more data while mysteries require interpreting data already collected.

In patient care we solve puzzles regularly. We collect data, develop competing hypotheses and then collect more data (lab tests, further history, imaging studies) and hopefully solve the puzzle. Some patients seem to represent a puzzle, but really are mysteries – their diagnoses just require a fresh interpretation of the collected data. CPCs are mysteries.

When panels develop guidelines they are trying to solve mysteries. They try to provide the best interpretation of known data to advise practicing physicians on the best strategy for treating a clinical situation.

The problem with medical mysteries is that we do not have a single correct answer. Rather we have probably answers, which depend on values.

Medical decision making is most complex because we can debate over which data to include in our decision making, and we can debate over the how to value potential benefits and potential harms. I like Malcolm Gladwell’s formulation, but I do not think it provides guidance on how we should make decisions.

Medicine has many puzzles and I believe solving puzzles remains a major skill for clinicians. Mysteries often transform into debates. Since we are interpreting data, our answer depends on our perception of utilities.

Gladwell did talk about the importance of time (a topic which I frequently address.) He acknowledges that we need enough time to address mysteries and puzzles. He also acknowledges that time is costly. The time dilemma remains the most important dilemma in health care.

As a long time member, and former President of SMDM, I am grateful to Malcolm Gladwell for addressing our society. His talk was great because he stimulated me to think. He has the wonderful skill of taking observations from diverse fields and constructing unifying observations.

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