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Big Decisions

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Quincy Young, PhD, RPsych
St. Paul's Hospital
Vancouver, BC, Canada

If you are like most people who work in medicine, you probably think that you make rational and purely data-driven medical decisions. Well, I'm going to kick off this article with some bad news for you. You don't. There is a substantial body of research describing cognitive errors and biases that come to play in decision making that often lead us to make irrational decisions. Medical decision making is not at all immune to these errors and biases, and may even be the perfect breeding ground for them [1-3].

As professionals working in the area of transplantation, we make difficult decisions all the time, with life-and-death consequences. The scarcity of suitable organs makes listing decisions in transplant more difficult than decision making in many other medical settings. And now I have more bad news for you. Because transplant listing decisions are often made collaboratively by groups of people, this kind of decision making is prey to a further host of problems that arise specifically in group contexts. This article will focus on three ways in which group dynamics can negatively affect the quality of decisions made by well-intentioned professionals working in groups [2].

The first is power dynamics. If you've ever been part of a group decision making discussion, I'm sure you've noticed that some people exert more influence than others over the final group decision. There is substantial empirical evidence that higher status group members have more influence than lower status members [4]. Sometimes this may be totally appropriate (due to knowledge, expertise, or role on the team). A surgeon's opinion should weigh more when the issue at hand is surgical in nature. At other times, however, this extra influence may simply be product of popularity or charm. For example, if some surgeon throws really amazing Christmas parties, or happens to be clever and amusing at rounds, the warm and fuzzy feelings this engenders may lead you to weigh her opinion more even when what is being considered is not a surgical issue.

A second problem goes by the name of "groupthink." Groupthink refers to the tendency of a group to strive for unanimity to such an extent that it interferes with critical thinking, and interferes with good decision making. In some cases group members will systematically avoid asking important questions or broaching topics about which there might be disagreement. Agreement is good, but so is a full-throated discussion of the many tricky issues that attend transplant decisions; and it is rarely good to prematurely agree to a bad decision. While it may be true that many people who work in medicine are quite willing to disagree with each other, humans in general do want to agree and it can be useful to realize that this tendency can affect group decision making outcomes.

A third group decision making dynamic to be aware of is the group polarization phenomenon [5]. This refers to the tendency for groups to make decisions that are more extreme than the initial inclination of its members.6 Group decisions may be extra risky if individuals' initial tendencies are to be risky, and these group decisions may be extra cautious if individuals' initial tendencies are to be cautious [6-7]. This shift happens for a variety of reasons. For example, in the process of participating in a transplant listing meeting, you may be exposed to other team members expressing opinions that support your own, and this may lead you to be even more certain that your opinion is correct [8]. There is empirical evidence that this group polarization does indeed affect decisions about the allocation of scarce medical resources. For example, one experiment involving the allocation of dialysis found that groups of three made final decisions that were more extreme than the decision made by three people individually [9].

So far I have shared nothing but bad news: A few of the many ways that group decision making can go sideways, and may lead to suboptimal medical decisions. Happily, I do have some good news too. There are some simple and straightforward ways of limiting these problems. In fact, there is evidence that just knowing about problematic group dynamics can mitigate their negative impact. So, congratulations! Just by reading this article you are already better off. Additional evidence shows that by putting some simple procedures in place, you can avoid a lot of the predictable problems that sometimes arise in group decision making [2]. Here are some things to do that help: Promote full and open discussions in your team meetings. Identify strategies to guard against premature agreement. Develop a planful approach to decision-making-and actually follow the plan!

At our center we have worked hard to do so. About 10 years ago we developed the Heart Transplant Decision Making Grid. We complete this document as a group whenever we make a transplant listing decision. You will see it is divided into 4 quadrants: Medical/ Surgical Contraindications; Psychosocial Contraindications; Lifestyle Management Contraindications; and a Decision Making Process checklist. We have found it to be very useful in focusing our discussions, helping us to evaluate multiple relative contraindications, and ultimately helping us to make fully-considered listing decisions. Especially relevant here is the quadrant on "Decision Making Process." It's just a short checklist, but it helps to ensure that we make an explicit effort to mitigate the negative impact of group decision making. I would encourage you to do something similar with your team. (Please feel free to use our Decision Making Grid, or to adapt it as needed.) By doing so, you may be able to better guard against problematic group dynamics, so that you can more fully avail yourselves of the many benefits of collaborative decision-making. ■

Disclosure Statement: The author has no conflicts of interest to disclose.


  1. McDermott R. Medical decision making: Lessons from psychology. Urologic Oncology: seminars and original investigations. 2008;26:665-668.
  2. Ross R. Small Groups in Organizational Settings. New Jersey: Prentice Hall. 1989, p 47-102.
  3. Bornstien B, and Emler A. Rationality in medical decision making: a review of the literature on doctors' decision-making biases. Journal of Evaluation in Clinical Practice. 2001;7:97-107.
  4. Davis J. Group Decision & Procedural justice. In: M. Fisbein, Editor. Progress in Social Psychology. Hillsdale, NJ: Erlbbaum. 1980, p 157-229.
  5. Isenberg D. Group Polarization: A Critical Review and Meta-Analysis. Journal of Personality and Social Psychology 1986;50: 1141-1151.
  6. Aronson E. Social Psychology. New Jersey: Prentice Hall. (2010). p. 273.
  7. Moscovici S, Doise W, Dulong R. Studies in group decision: II. Differences of positions, differences of opinion, and group polarization. European Journal 1972;2:385-399.
  8. Myers D, & Lamm H. The polarizing effect of group discussion. American Scientist 1972;63: 297-303.
  9. Furnham A, Simmons K, and McClelland A. Decisions concerning the allocation of scare medical resources. Journal of Social Behavior and Personality. 2000;15(2):185-200.

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