Hunink MEDICAL DECISION MAKING VOL 21/NO 4, JULY–AUG 2001 Logical Medical Decision Making In Search of Tools to Aid Logical Thinking and Communicating about Medical Decision Making M. G. MYRIAM HUNINK, MD, PhD To have real-time impact on medical decision making, decision analysts need a wide variety of tools to aid logical thinking and communication. Decision models provide a formal framework to integrate evidence and values, but they are commonly perceived as complex and difficult to understand by those unfamiliar with the methods, especially in the context of clinical decision making. The theory of constraints, introduced by Eliyahu Goldratt in the business world, provides a set of tools for logical thinking and communication that could potentially be useful in medical decision making. The author used the concept of a conflict resolution diagram to analyze the decision to perform carotid endarterectomy prior to coronary artery bypass grafting in a patient with both symptomatic coronary and asymptomatic carotid artery disease. The method enabled clinicians to visualize and analyze the issues, identify and discuss the underlying assumptions, search for the best available evidence, and use the evidence to make a well-founded decision. The method also facilitated communication among those involved in the care of the patient. Techniques from fields other than decision analysis can potentially expand the repertoire of tools available to support medical decision making and to facilitate communication in decision consults. Key words: medical decision making; theory of constraints; communication. (Med Decis Making 2001;21:267–277) The Story Being a vascular radiologist, I regularly attend the vascular conference at the university hospital. It’s an interesting conference: The professor of surgery loves academic discussions, and each case receives much attention. The conference usually takes 3 hours. The clinical fellows complain, of course, and it certainly keeps me from my regular work of writing proposals and papers. But it’s one of the few conferences that I attend where there is a real discussion of the risks and benefits, and the costs, of the management options. Even patient pref- erences are sometimes (albeit rarely) considered. But a few weeks ago I started getting fed up with the whole thing. The discussions always seem to go along the same lines: Dr. Smith says that he feels that treatment X is the right thing to do because he recently read a paper that mentioned that X was beneficial; Dr. Johnson counters that X has a substantial risk associated with it, as was shown in the paper published last year in the world’s highest ranking journal in the field, and should therefore not be considered; and Dr. Gray says that given the current limited budget in the department, maybe we should consider a less expensive alternative or no treatment at all. After talking around in circles for about 10 to 15 minutes, with each doctor reiterating his or her opinion and new facts popping up from time to time, the professor of vascular surgery finally stops the discussion, realizing that his fellows are getting irritated because they have work to do. Practical chores are waiting. And so the professor concludes, “Okay. So it seems we should be doing treatment X.” About 40% of those involved in the decision-making process nod their heads in agreement, another 40% start bringing up objections (which get stifled quickly by the fellows who really don’t want an encore), and the remaining 20% of those involved are either too tired or too flabbergasted to respond or are optimizing another goal in life, namely, job security. Does this sound familiar? So I decided I needed to do something that would make the conference more productive, possibly 267 Received 2 March 2000 from the Assessment of Radiological Technology (ART) program, Department of Radiology and the Department of Epidemiology and Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands; and the Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts. Revision accepted for publication 9 March 2001. Address correspondence and reprint requests to Dr. Hunink: Department of Radiology and Department of Epidemiology and Biostatistics, Erasmus University Medical Center, Room EE21-40a, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands; telephone: 31 10 408 7391; fax: 31 10 408 9382; e-mail: hunink@epib.fgg.eur.nl.