Blink: The Power of Thinking Without Thinking

signature of a complex phenomenon. All you need is the evidence of the ECG, blood pressure, fluid in the lungs, and unstable angina.

That’s a radical statement. Take, for instance, the hypothetical case of a man who comes into the ER complaining of intermittent left-side chest pain that occasionally comes when he walks up the stairs and that lasts from five minutes to three hours. His chest exam, heart exam, and ECG are normal, and his systolic blood pressure is 165, meaning it doesn’t qualify as an urgent factor. But he’s in his sixties. He’s a hard-charging executive. He’s under constant pressure. He smokes. He doesn’t exercise. He’s had high blood pressure for years. He’s overweight. He had heart surgery two years ago. He’s sweating. It certainly seems like he ought to be admitted to the coronary care unit right away. But the algorithm says he shouldn’t be. All those extra factors certainly matter in the long term. The patient’s condition and diet and lifestyle put him at serious risk of developing heart disease over the next few years. It may even be that those factors play a very subtle and complex role in increasing the odds of something happening to him in the next seventy-two hours. What Goldman’s algorithm indicates, though, is that the role of those other factors is so small in determining what is happening to the man right now that an accurate diagnosis can be made without them. In fact—and this is a key point in explaining the breakdown of Blue Team that day in the Gulf—that extra information is more than useless. It’s harmful. It confuses the issues. What screws up doctors when they are trying to predict heart attacks is that they take too much information into account.

The problem of too much information also comes up in studies of why doctors sometimes make the mistake of missing a heart attack entirely—of failing to recognize when someone is on the brink of or in the midst of a major cardiac complication. Physicians, it turns out, are more likely to make this kind of mistake with women and minorities. Why is that? Gender and race are not irrelevant considerations when it comes to heart problems; blacks have a different overall risk profile than whites, and women tend to have heart attacks much later in life than men. The problem arises when the additional information of gender and race is factored into a decision about an individual patient. It serves only to overwhelm the physician still further. Doctors would do better in these cases if they knew less about their patients—if, that is, they had no idea whether the people they were diagnosing were white or black, male or female.

It is no surprise that it has been so hard for Goldman to get his ideas accepted. It doesn’t seem to make sense that we can do better by ignoring what seems like perfectly valid information. “This is what opens the decision rule to criticism,” Reilly says. “This is precisely what docs don’t trust. They say, ‘This process must be more complicated than just looking at an ECG and asking these few questions. Why doesn’t this include whether the patient has diabetes? How old he is? Whether he’s had a heart attack before?’ These are obvious questions.

They look at it and say, ‘This is nonsense, this is not how you make decisions.’” Arthur Evans says that there is a kind of automatic tendency among physicians to believe that a life-or-death decision has to be a difficult decision. “Doctors think it’s mundane to follow guidelines,” he says. “It’s much more gratifying to come up with a decision on your own. Anyone can follow an algorithm. There is a tendency to say, ‘Well, certainly I can do better. It can’t be this simple and efficient; otherwise, why are they paying me so much money?’” The algorithm doesn’t feel right.

Many years ago a researcher named Stuart Oskamp conducted a famous study in which he gathered together a group of psychologists and asked each of them to consider the case of a twenty-nine-year-old war veteran named Joseph Kidd. In the first stage of the experiment, he gave them just basic information about Kidd. Then he gave them one and a half single-spaced pages about his childhood. In the third stage, he gave each person two more pages of background on Kidd’s high school and college years. Finally, he gave them a detailed account of Kidd’s time in the army and his later activities. After each stage, the psychologists were asked to answer a twenty-five-item multiple-choice test about Kidd. Oskamp found that as he gave the psychologists more and more information about Kidd, their confidence in the accuracy of their diagnoses increased dramatically. But were they really getting more accurate? As it turns out, they weren’t. With each new round of data, they would go back over the test and change their answers to eight or nine or ten of the questions, but their overall accuracy remained pretty constant at about 30 percent.

“As they received more information,” Oskamp concluded, “their certainty about their own decisions became entirely out of proportion to the actual correctness of those decisions.” This is the same thing that happens with doctors in the ER. They gather and consider far more information than is truly necessary because it makes them feel more confident—and with someone’s life in the balance, they need to feel more confident. The irony, though, is that that very desire for confidence is precisely what ends up undermining the accuracy of their decision. They feed the extra information into the already overcrowded equation they are building in their heads, and they get even more muddled.

What Reilly and his team at Cook County were trying to do, in short, was provide some structure for the spontaneity of the ER. The algorithm is a rule that protects the doctors from being swamped with too much information—the same way that the rule of agreement protects improv actors when they get up onstage. The algorithm frees doctors to attend to all of the other decisions that need to be made in the heat of the moment: If the patient isn’t having a heart attack, what is wrong with him? Do I need to spend more time with this patient or turn my attention to someone with a more serious problem? How should I talk to and relate to him? What does this person need from me to get better?

“One of the things Brendan tries to convey to the house staff is to be meticulous in talking to patients and listening to them and giving a very careful and thorough physical examination—skills that have been neglected by many training programs,” Evans says. “He feels strongly that those activities have intrinsic value in terms of connecting you to another person. He thinks it’s impossible to care for someone unless you know about their circumstances—their home, their neighborhood, their life. He thinks that there are a lot of social and psychological aspects to medicine that physicians don’t pay enough attention to.” Reilly believes that a doctor has to understand the patient as a person, and if you believe in the importance of empathy and respect in the doctor-patient relationship, you have to create a place for that. To do so, you have to relieve the pressure of decision making in other areas.

There are, I think, two important lessons here. The first is that truly successful decision making relies on a balance between deliberate and instinctive thinking. Bob Golomb is a great car salesman because he is very good, in the moment, at intuiting the intentions and needs and emotions of his customers. But he is also a great salesman because he understands when to put the brakes on that process: when to consciously resist a particular kind of snap judgment. Cook County’s doctors, similarly, function as well as they do in the day-to-day rush of the ER because Lee Goldman sat down at his computer and over the course of many months painstakingly evaluated every possible piece of information that he could. Deliberate thinking is a wonderful tool when we have the luxury of time, the help of a computer, and a clearly defined task, and the fruits of that type of analysis can set the stage for rapid cognition.

The second lesson is that in good decision making, frugality matters. John Gottman took a complex problem and reduced it to its simplest elements: even the most complicated of relationships and problems, he showed, have an identifiable underlying pattern. Lee Goldman’s research proves that in picking up these sorts of patterns, less is more. Overloading the decision makers with information, he proves, makes picking up that signature harder, not easier. To be a successful decision maker, we have to edit.

When we thin-slice, when we recognize patterns and make snap judgments, we do this process of editing unconsciously. When Thomas Hoving first saw the kouros, the thing his eyes were drawn to was how fresh it looked. Federico Zeri focused instinctively on the fingernails. In both cases, Hoving and Zeri brushed aside a thousand other considerations about the way the sculpture looked and zeroed in on a specific feature that told them everything they needed to know. I think we get in trouble when this process of editing is disrupted—when we can’t edit, or we don’t know what to edit, or our environment doesn’t let us edit.

Remember Sheena Iyengar, who did the research on speed-dating? She once conducted another experiment in which she set up a tasting booth with a variety of exotic gourmet jams at the upscale grocery store Draeger’s in Menlo Park, California. Sometimes the booth had six different jams, and sometimes Iyengar had twenty-four different jams on display. She wanted to see whether the number of jam choices made any difference in the number of jams sold. Conventional economic wisdom, of course, says that the more choices consumers have, the more likely they are to buy, because it is easier for consumers to find the jam that perfectly fits their needs. But Iyengar found the opposite to be true. Thirty percent of those who stopped by the six-choice booth ended up buying some jam, while only 3 percent of those who stopped by the bigger booth bought