The Azimuth Project
Blog - making decisions under uncertainty

This is a blog article in progress, written by Curtis Faith. For the final polished version, go to the Azimuth Blog.

Saving the planet will not be easy. We know what the most urgent problems are, but there is too much uncertainty to predict any particular outcomes or events with precision.

So what are we to do? How do we formulate strategy and plans to avert or mitigate disasters? How do we plan for problems when we don’t know exactly what form they will take?

Seven rules for risk and uncertainty

As I noted in my previous blog post, from my experience as a trader, an entrepreneur, and what what I learned about how emergency room (ER) doctors manage risk and uncertainty, those who are confronted with uncertainty as part of their daily lives use a similar strategy for managing that uncertainty. Further, the way they make decisions and develop plans for the future is very relevant to the Azimuth project.

My second book, Inside the Mind of the Turtles, described this strategy in detail. In the book, I outlined seven rules for managing risk and uncertainty. They are:

  • Overcome fear,
  • Remain flexible,
  • Take reasoned risks,
  • Prepare to be wrong,
  • Actively seek reality,
  • Respond quickly to change, and
  • Focus on decisions, not outcomes.

Most of you are familiar with many of the aspects of life-or-death emergencies, having experienced them when you or a loved one has been seriously sick or injured. So it may be a little easier to understand these rules if you examine them from the perspective of an ER doctor.

Overcome fear

Risk is everywhere in the ER. You can’t avoid it. Do nothing, and the patient may die. Do the wrong thing, and the patient may die. Do the right thing, and the patient still may die. You can’t avoid risk.

At times, there may be so many patients requiring assistance that it becomes impossible to give them all care. Yet decisions must be made. The time element is critical to emergency care, and this greatly increases the risk associated with delay or making the wrong decisions. The doctor must make decisions quickly when the ER is busy, and these decisions are extremely important. Unlike in trading or in a startup, in the ER, mistakes can kill someone.

To be a successful as an ER doctor, you must be able to handle life-or-death decisions every day. You must have the confidence in your own abilities and your own judgment to act quickly when there is very little time. No doctor who is afraid to make life-or-death decisions stays in ER for very long.

Remain flexible

One of the hallmarks of an ER facility is the ability to act very quickly to address virtually any type of critical medical need. A well-equipped ER will have diagnostic and surgical facilities onsite, defibrillators for heart attack victims, and even surgical tools for those times when a patient may not survive the trip up the elevator to a full surgical suite.

Another way that an ER facility organizes for flexibility is by making sure that there are sufficient doctors with a broad range of specialties available. ERs don’t staff for the average workload; they staff for the maximum expected workload. They keep a strategic reserve of doctors and nurses available to assist in case things get extremely busy.

Take reasoned risks

Triage is one way of managing the risks associated with the uncertainty of medical diagnoses and treatments. Triage is a way of sorting patients so those who require immediate assistance are helped first, those in potentially critical situations next, and those in no imminent danger of further damage are helped last. For example, if you go to the ER with a broken leg, you may or may not be the first person in line for treatment. If a shooting victim comes in, you will be shuffled back in line. Your injury, while serious, can wait because you are in little danger of dying, and a few hours’ delay in setting a bone is unlikely to cause permanent damage.

Diagnosis itself is one of the most important aspects of emergency treatment. The wrong diagnosis can kill a patient. The right diagnosis can save a life. Yet diagnosis is messy. There are no right answers, only probable answers.

Doctors weigh the probability of particular diseases or injuries against the seriousness of outcomes for the likely conditions and the time sensitivity of a given treatment. Some problems require immediate care, whereas some are less urgent. Good doctors can quickly evaluate the symptoms and results of diagnostic tests to deliver the best diagnosis. The diagnosis may be wrong, but a good doctor will evaluate the factors to determine the most likely one and will continue to run tests to eliminate rarer but potentially more serious problems in time to effect relevant treatment.

Prepare to be wrong

A preliminary diagnosis may be wrong; the onset of more serious symptoms may indicate that a problem is more urgent than anticipated initially. Doctors know this. This is why they and their staff continuously monitor the health status of their patients.

Often while the initial diagnosis is being treated doctors will order additional tests to verify the correctness of that initial diagnosis. They know they can be wrong in their assessment. So they allow for this by checking for alternatives even while treating for the current diagnosis.

More than perhaps any other experts in uncertainty, doctors understand the ways that uncertainty can manifest itself. As a profession, doctors have almost completely mapped the current thinking in medicine into a large tree of objective and even subjective tests that can be run to confirm or eliminate a particular diagnosis. So a doctor knows exactly how to tell if she is wrong and what to do in that event almost every time she makes a diagnosis. Doctors also know which other, less common medical problems also can exhibit the same symptoms that the previous diagnosis did.

For example, if a patient comes in with a medium-grade fever, a doctor normally will check the ears, nose, sinuses, lymph nodes, and breathing to eliminate organ-specific issues and then probably issue a diagnosis of a flu infection. If the fever rises above 102 degrees (39C), the doctor probably will start running some tests to eliminate more serious problems, such as a bacterial infection or viral meningitis.

Actively seek reality

Since doctors are not 100 percent certain that the diagnosis they have made for a given patient is correct, they continue to monitor that patient’s health. If the patient is in serious danger, he will be monitored continuously. Anyone who visits a hospital emergency room will notice all the various monitors and diagnostic machines. There are ECG monitors to check the general health of the heart, pulse monitors, blood oxygenation testers, etc. The ER staff always has up-to-the-second status for their patients. These immediate readings alert doctors and nurses quickly to changes indicating a worsening condition.

Once the monitors have been set up (generally by the nursing staff), ER doctors double-check their diagnosis by running tests to rule out more serious illnesses or injuries that may be less common. The more serious the patient’s condition, the more tests will be run. A small error in diagnosis may cost a patient’s life if she suffers from a serious condition with poor vital signs such as very low blood pressure or an erratic pulse. A large error in diagnosis may not matter for a patient who is relatively healthy. So more time and effort are spent to verify the diagnoses of patients with more serious conditions, and less time and effort are spent verifying the diagnoses of stable patients.

Actively seeking reality is extremely important in emergency medicine because initial diagnoses are likely to be in error to some degree a significant percentage of the time. Since misdiagnoses can kill people, much time and effort are spent to verify and check a diagnosis and to make sure that a patient does not regress.

Respond quickly to change

If caught early, a misdiagnosis or a significant change in a patient’s condition need not be cause for worry. If caught late, it can mean serious complications, extended hospitalization, or even death. For critical illness and injury, time is very important.

The entire point of closely monitoring a patient is to enable the doctor to quickly determine if there is something more serious wrong than was first evident. A doctor’s initial diagnosis comes from the symptoms that are readily apparent. A good doctor knows that there may be a more serious condition causing those symptoms. More serious conditions often warrant different treatment. Sometimes a patient’s condition is serious enough that a few hours can mean the difference between life and death or between full recovery and permanent brain damage.

For example, a mother comes into the ER with her preteen son, who is running a fever of 102 degrees (39C), has a headache, and is vomiting. These are most likely symptoms from a flu infection that is not particularly emergent. The treatment for the flu is normally just bed rest and drinking lots of fluids. So, if the ER is busy, the flu patient normally will wait as patients with more urgent problems get care.

The addition of one more symptom may change the treatment completely. If the patient who may have been sitting in the ER waiting room starts complaining of a stiff painful neck in addition to the flu symptoms, this may be indicative of spinal meningitis, which is a life-threatening disease if not treated quickly. The attending physician likely will order an immediate lumbar puncture (also called a spinal tap) to examine the spinal fluid to see if it is infected with the organisms that cause spinal meningitis. If it is a bacterial infection, treatment with antibiotics will begin right away. A few hours difference can save a life in the case of bacterial spinal meningitis.

The important thing to remember is that a good doctor knows what to look for that will indicate a more serious condition than was indicated initially. She also will respond very quickly to administer appropriate treatment when the symptoms or tests indicate a more serious condition. A good doctor is not afraid of being wrong. A good doctor is looking for any sign that she might have been wrong so that she can help the patient who has a more serious disease in time to treat it so the patient can recover completely.

Focus on decisions, not outcomes

One of the difficulties facing ER doctors because of the uncertainty of medical diagnoses and treatments is the fact that a doctor can do everything correctly, and the patient still may die or suffer permanent damage. The doctor might perform perfectly and still lose the patient.

At times, a patient may require risky surgery to save his life. The doctor will weigh the risk of the surgery itself against the risk of alternative treatments. If the surgery will increase the chances of the patient surviving, then the doctor will order the surgery or perform it herself in cases of extreme emergency.

A doctor may make the best decision under the circumstances using the very best information available, and still the patient may die. A good doctor will evaluate the decision not on the basis of how it turns out but according to the relative probabilities of the outcomes themselves. An outcome of a dead patient does not mean that surgery was a mistake. Likewise, it may be that the surgery should not have been performed even when it has a successful outcome.

If ER doctors evaluated their decisions on the basis of outcomes, then it would lead to bad medicine. For example, if a particular surgery has a 10 percent mortality rate, meaning that 10 percent of the patients who have the surgery die soon after, this is risky surgery. If a patient has an injury that will kill the patient 60 percent of the time without that surgery, then the correct action is to have the surgery performed because the patient will be six times more likely to live with it than without it. If an ER doctor orders the surgery and it is performed without error, the patient still may die. This does not change the fact that absent any new information, the decision to have the surgery still was correct.

The inherent uncertainty of diagnosis and treatment means that many times the right treatment will have a bad outcome. A good doctor knows this and will continue prescribing the best possible treatment even when a few rare examples cross her path.

Relevance for Azimuth

Like an ER doctor trying to diagnose a patient in critical condition, we don’t have much time. We need to prepare ourselves so that when problems arise and disaster strikes, we can quickly determine what’s wrong, stabilize the patient, make sure we have found all the problems, monitor progress, and maintain vigilance until the patient has recovered.

The sheer complexity of the issues, and the scope of the problems that endanger the planet and life on it, ensure that there will never be enough information to make a “correct” analysis, or one single foolproof plan of action. Except in the very broadest terms, we can’t know what the future will bring so we need to build plans that acknowledge that very real limitation.

Rather than pretend that we know more than is possible to know we should embrace the uncertainty. We need to build flexible organizations and structures so that we are prepared to act no matter what happens. We need to build flexible plans that can accommodate change.

We need to build the capability to acquire and assimilate an understanding of reality as it unfolds. We need to seek the truth about our condition and likely prospects for the future.

And we need to be willing to change our minds when circumstances indicate that our judgments have been wrong.

Being ready for any potential scenario will not be easy. It will require a tremendous effort on the part of a global network of scientists, engineers, and others who are interested in saving the planet.

I hope that you consider joining our effort.

category: blog