By Brian McCardel, MD
When I read Joel’s recent post on the importance of decisive leadership, I jumped all over the opportunity to respond. I have spent a great deal of time thinking about decision-making, mine and that of others, and it has been a topic of my conversations with Joel for many years.
I would like to start off with one of my favorite stories about decision-making from that sage known for his incisive statements, Yogi Berra. Yogi wrote a number of books over the years, and one of my personal favorites is “When You Come to a Fork in the Road, Take It!” The title expression, like so many other things he said, is wise advice wrapped in a clownish use of English. The book’s key insight: you shouldn’t spend too much time trying to figure out the answer to puzzles that don’t have one. He noted that many people get to decision points, or “forks in the road,” only to dawdle. You should recognize the decision for what it is, make a responsible decision based on the available facts, and MOVE ON. I loved this explanation as it reinforced some sage advice that I got early in my practice as an orthopedic surgeon.
I was out to lunch with my friend Jake, a priest, when he offered me this life-changing insight. I was telling him about how I was beating myself up over a clinical outcome, though I really didn’t understand what had gone wrong. Over the clamor of dishes in a crowded Italian diner he said, “What you are struggling with is the difference between prudential and absolute certitude.” Naturally, I answered, “What? I must not have heard you right.” He repeated himself, and I told him that this time I had heard him, but had no idea what he meant. He then explained:
Prudential certitude is being as certain in a decision-making situation as a prudent person should be. This includes gathering the available facts, doing the analysis, considering the consequences and allowing one to be prudentially certain of one’s decision.
Absolute certitude is always knowing the right answer based on perfect facts and understanding. That is God’s domain. As my friend directed, “And you, sir, are not God. Get over it. Because until you do, you will be miserable, and do a disservice to your patients, your family and your friends.”
That insight was jarring, of course, but in the best possible way. I sat there stunned – and also like the weight of the world was lifted from me. It changed my life, and I have been forever grateful. Learning to practice prudential certitude has extended beyond my clinical practice. I have become a better decision-maker in my life – starting with the recognition that there is a difference between problems and dilemmas. Problems have solutions. And dilemmas do not. Many people spend a great deal of time trying to provide solutions to dilemmas. No wonder they take so long! When making a decision, first define if what you are considering is consequential: a decision on a large capital investment or on where to go for lunch. If inconsequential, make a decision and move on. If it is consequential, figure out if you are dealing with a problem or with a dilemma. If it is a consequential problem, get to prudential certitude as soon as is practicable, and like Yogi, move on!