Bounded rationality, medicine and the internet age.

Clinicians use simple heuristics (rules) to guide their judgement until they reach a 'saturation point'. They have 'bounded rationality' that means they are not entirely rational and this helps them cope with the complexity of their practice.

"‘Saturation point’ was defined as the moment when physicians decide to stop using heuristics. It could be reached either because physicians confirmed a hypothesis or because they halted the process until further discussion was held with peers or they could wait for further evolution of their patients' condition. This method of limiting and stopping the search as soon as they felt satisfied with the decision is part of Simon & Selteńs models of bounded rationality. As soon as the physician using hypothesis-specific heuristics with a positive test strategy found a pattern, the process was stopped and a diagnosis was reached. This process could be delayed when there were many cues to the diagnosis that needed to be refuted. The effort to refute cues lead to a reduction in physician's confidence and a rise in uncertainty levels. Contradictions from the environment, particularly contradicting peer opinion led to the same result. Confidence in own judgment is also found to be an important factor in decision making whereby employing heuristics. In our study, confidence was a chief factor for establishing the saturation point, but it certainly was not the only component. For instance, time pressure, although not observed in this study, must be taken into account, and further study should be conducted in this area." [1]

The authors go on to make suggestions for the construction of clinical practice guidelines.

Reading this made me think about what are the implications for the use of 'emerging technologies' in medicine. Apart from the 'early adopters' of technology these new digital tools of social media, ubiquitous web and the analysis of data from electronic health records, represent added complexity - not necessarily simpler healthcare.

Herbert Simon was rewarded for his work on the rational decision making in business organization with the Nobel Prize for economics in 1978. Has this concept of 'bounded rationality' - that individuals aren't as smart as they may think they are and develop simpler techniques and rules to survive in complex environments - helped the world of economics? Is it true that everybody knew what they were doing with complex financial derivatives that turned out to be toxic debt in the 2008 crash? Did anyone understand them? The problem was they took emerging technologies and created new simple business rules to maximise the benefit of the technologies but assuming there was little or predictable risk.

I wonder if we are sometimes also at risk of introducing new and simple rules for healthcare professionals to help convince them of the utility of emerging technologies.

If you all you have is a hammer then everything looks like a nail. (Maslow's Law of the Instrument). Also, if you are obsessed with an emerging technology then everything looks like it is amenable to it.

We need to help develop effective heuristics for engaging with emerging technologies that are of proven value for improving patient care.


1. Bonilauri Ferreira APR, Ferreira RF, Rajgor D, Shah J, Menezes A, Pietrobon R. Clinical reasoning in the real world is mediated by bounded rationality: implications for diagnostic clinical practice guidelines. PLoS ONE 2010;5(4):e10265. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20421920