How Do Managers Think?

"Uncertainty sometimes is essential for success" asserts a new book, How Doctors Think. The work of doctors raises intriguing questions about managing, says Jim Heskett, since diagnostics are an important part of managerial decision-making, too. Jim sums up nearly 60 responses from readers around the world, including practicing physicians.
by Jim Heskett

Summing Up

Can managers acquire ways of thinking or ways of learning from doctors?

Managers can learn from an understanding of how doctors think. But whether the lessons are profound or even totally applicable was a matter of discussion among respondents to this month's column. What was intriguing was a suggestion that while managers might have little to learn from doctors about thinking, there might be more important implications for managers in the ways that doctors are trained.

Many similarities were observed between the thinking of medical and management practitioners and the environments in which it is carried out. Joe Schmid observed that "both medical doctors and organizational managers work in cultures that are historically problem definition poor and solution rich. Their individual rewards systems are both driven by 'throughput.'" Joanne Celens opined that "the key success factor—like with doctors … (is) management's willingness to hear … as input in their decision processes." Alberto Souto said, "Both medicine and management are socio-technologies … plus art …. There is still a lot of craftsmanship in these two disciplines."

Richard Kunjawa suggested that "… doctors rush when the illness is serious … managers, when faced with little time and pressure to get things done, fail to think well and so make poor decisions." Itamar Offer, a physician, said that "information is always partial in both professions … there is no substitute for listening to others …." Bill Welter opined that "… the basic cycle that all thinking professionals (doctors and managers alike) should use (is): to sense, to make sense, to decide, and to act …. Unfortunately, too few of us deem 'thinking' to be real work." C.J. Cullinane wrote, "The concept of people, be they patient or employee, holding back information either knowingly or just forgetting, is a problem that can kill a patient or a company."

Others suggested important contrasts that they think make comparisons less relevant. William James Dorman commented, "Interesting to make analogies, but the basics of medical decision making are grounded in scientific fact whereas there is no unified body of knowledge based on science for the manager." As Todd Rhoad put it, "… doctors … are trained troubleshooters. It takes many years to learn to operate using such a scientific method in solving problems …. Managers focus on making decisions with little information, not through a rigorous review of the details." According to Gerald Nanninga, "A big difference between doctors and managers is the fact that the doctor's patients realize they are sick and proactively seek out the doctor …. A good manager needs to get more involved in 'preventative medicine ….'" Akhil Mehta, before observing similarities, pointed out that "… human life is almost never involved in managerial decision making." Siva Subramaniam commented that "the metric for measuring the doctor's work is a near perfect solution while the manager has to deliver the most effective outcome vis-à-vis original plans."

One interesting comment about what managers can learn was offered by Darryl Duncan, who asked, "I wonder if we do a good enough job of educating our employees to recognize symptoms of 'poor health' so that they are able to self-identify themselves to their managers?" And Ulysses U. Pardey said, "(In their training, doctors) are in real contact with what they must understand …. The ways and tools used to teach and understand medicine allow doctors to be hands-on today with what will be their job tomorrow …. Will future managers have the privilege to experience and acquire practical understanding within real-life companies … (as a) complementary device to business school teaching and learning?" What do you think?

Original Article

Ask an artist how she creates a work of art, and chances are she can't tell you in a way that would enable you to do it. Similarly, managers I've observed over the years have great difficulty dissecting how they make tough decisions. Now we have an intriguing book, How Doctors Think, in which a practicing doctor, Jerome Groopman, describes brilliant diagnoses and treatments. The book is of particular interest because our colleagues at Groopman's institution, the Harvard Medical School, have evidenced a long-standing interest in business school-type case method techniques, including the development of an instructional program based on them.

Perhaps most important, Groopman describes how and why doctors sometimes make tragic mistakes. These are mistakes that occur because of miscommunication (the failure to say "tell me again"); too heavy a reliance on pattern recognition; a tendency to draw on stereotypes to make decisions regarding patients; premature closure of problem diagnosis, possibly because of too heavy a reliance on first impressions; framing effects (biases or preconceptions caused by others’ opinions or diagnoses); and availability (judging on the basis of the "ease with which relevant examples come to mind"). In his words, the diagnostic process is even "compromised by positive or negative feelings we have toward another person." Putting it bluntly, research has shown that doctors are more patient when diagnosing people who are not seriously ill, troublesome, or chronic in their complaints. And getting things right takes time, time that many doctors just don't have (or think they don't have).

More successful doctors work hard at something called "patient activation and engagement," primarily by asking open-ended questions whose purpose is to engage patients with the purpose "to wake someone up" and signal that the doctor is inviting a dialogue about a patient's ailments. In fact, Groopman asserts that "how a doctor thinks can first be discerned by how he speaks and how he listens…his attention to the body language of his patient as well as his own body language."

The process proceeds with questions designed to open the exploration of diagnoses that don’t fit usual patterns or preconceptions. Its success may depend on questions posed by the "awakened" patient, questions such as "Can I tell you again about how I feel, how it happened, etc.?" "What else could it be?" "Is there anything that doesn't fit?" And "is it possible I have more than one problem?" The very best doctors are able to say, "I believe you when you say something is wrong, but I haven't figured it out," possibly voluntarily sending you on to another doctor for his opinion. This takes time, and good doctors make time to do it. Does this sound like your doctor?

Even though doctors may sometimes avoid full disclosure to patients for fear of disturbing them, Groopman asserts that "uncertainty sometimes is essential for success." These observations about doctors raise some interesting questions about how we manage. After all, diagnostics are an important part of managerial decision-making, whether or not someone's life is on the line. What, if anything, can managers learn from Dr. Jerome Groopman's findings and hypotheses? To what degree do they help explain how managers think? Can we learn about good diagnostic procedure by observing our medical counterparts? What do you think?

To read more:
Jerome Groopman, How Doctors Think (Boston: Houghton Mifflin Company, 2007).

    • Ray Simkus
    • physician
    I picked up "How Doctor's Think" last week and have read half of it so far. This is an excellant book with very good examples of how things can go wrong. I have been working as a GP for 30 years and have been interested in clinical decision making throughout that time. The examples in the book deal with specialists. As a generalist I find that the issues of uncertainty are multiplied relative to what the specialists deal with. We have to make decisions with even less data and at an earlier stage than the specialists. An interesting sequel could be "How GPs Think" as we deal with a different population of patients and have different issues to deal with.

    What clues do we use to decide whether to send a patient home with chest pain or call for an ambulance to take them to a hospital? How do we deal with patients on a 7 miinute encounter while it has be reported that it should take about 18 minutes to do all that we are supposed to do? How can we keep up to date with the tidal wave of new information, new information that sometimes reverses previously held dictums? Other times the new information confirms what the GPs have known for many years already.

    "How Doctors Think" is a good read and I am looking forward to having time to finish it.

    Ray Simkus MD, CM
    Langley, BC
    • Sudhir Desai
    • Managing Consultant, IBM, Global Business Services
    The practitioner (doctor, manager or other) typically uses a well-defined framework which prescribes approaches to problem solving for a well defined set of problems. It is natural for practitioners to therefore look at any problem situation from a worldview that is familiar to them, finding ways to fit evidence to their framework and ignoring facts that they cannot comprehend, since their ways of knowing do not provide an explanation.

    The biases listed are true to all humans and not limited to doctors alone. Organizations practice various methods to avoid such biases consciously or otherwise so that multiple perspectives of peers and colleagues might lead to better decisions, though we are as likely to see group biases come into play as well. Doctors often find themselves in situations where they may not have the opportunity to engage others.

    I think the most important issue here is to understand whether the practice, medicine or other, is limited and restricted in its worldview. To the extent that the doctor is willing and trained to engage the patient from a broader perspective and willing to admit that not all healing might lie within the domain of his or her practice, we can expect to see fewer failures. However, that is not how our professions practice in most cases.
    • Itamar Offer
    • CEO, Neotia Elbit Hospital Venture Ltd.
    Having expeience in both medicine and management (being a senior pediatrician for 6 years and a manager for the last 9 years) I would love to comment.

    My feeling is that working as a senior physician in a teaching hospital might be one of the best schools for decision making.

    The uniqueness of doctors' decision making (which is not always about diagnosis) is that in teaching hospitals, as well as in senior management, all responsibility and accountability rests on the shoulders of one person - the senior physician/manager.

    Information is always partial in both professions. Even if you do all the exercises needed to obtain the best information from the patient - it is not always true, it is biased in many aspects and it might sometime even interfere with making the right diagnosis.

    In summary, I believe that there is no substitute to listening to others i.e. patients as well as colleagues from all disciplines; but in the end, the person who is in charge makes the decision.

    Ahhh - of course - sometime we should be open to change the decision if we find them problematic - and avoid "falling in love" with our own decisions.
    • Raed Al-Adl
    • York University - Toronto
    The article along with the question raised are very interesting, because it's beneficiary to everyone in business or other fields to cross learn from each other. While doctors' decisions are far more important than a business manager's because they relate to human life and well being of a person, they have a single thing in common: the decision will have consequences that affect others (either a company, department, or health of a person).

    I believe the mechanism through which every person takes a decision is similar and different whether they are doctors or in any other profession. We analyze our information (diagnosis) and reach a decision based on our training, experience and circumstances attached.

    The article would raise also a great question: how do we cross-learn from each other, what does a doctor that will help managers in corporations diagnose problems and come up with better decisions, and how can business managers can help doctors through their techniques to tackle problems, communicate issues and manage risks involved?

    Being a manager and having cross-departmental experience, I see that such cross-learning will always shed a light on angles that we ignored or didn't know existed. Marketing would make better decisions if they learnt to think from production/financial and human resources angles along with their own. Doctors can learn from managers and managers can learn how to take instant decisions in a very stressful environment. If managers think like doctors then corporations would have a much better ratio when it comes to bad decisions.
    • Oscar
    • Controller, Marmolera Leonesa (Spain)
    A doctor is a link more within the sanitary half-framed complex. When a person goes to a sanitary unity, the first diagnosis of the doctor is especially key. The communication with the patient and active listening are important allies; an effective diagnosis supposes to recover the patient and to avoid future expenses (worsening of the disease and new recognitions). For that reason, the areas of first attention or urgencies of the hospitals are "reconstructed."

    In the business world the detection of the first "symptoms" also is especially important. In the process of decision- making, although the managers finally decide, all and each one of the members of an organization have their greater or smaller degree of responsibility. The vertical and horizontal communication and the organizational learning are essential elements.
    • Girish Shah
    • Executive VP, Agile Business Consultants
    Good Managers think differently under different situations while staying consistent with their "personal values" by actively listening to their inner voice / intuition and their advisers. Most of the time they weigh different implications on all involved constituencies as well as their financial and non-financial impacts.

    They evaluate the data they have, figure out what info they have and what they need, then make assumptions while questioning the basis for assumptions, and may seek advice from experts.

    While under pressure (from wherever - stock holders, board, sr. managers) for short term results, they at times pay a price by making suboptimal decisions.
    • Mohamed Ashraf Iqbal
    • Director, MindSpring Sdn Bhd
    My entire consulting work is built on the premise that if I can change the way people think in organizations, I can change the performance of organizations. Engagement after engagement, my clients see the power of "meta thinking," of thinking about what we are thinking about, and they see it in their P&L's (income statement's). This is what I call "Accelerated Business improvement."

    By thinking about what you are thinking about, it dramatically slows down the rate at which we jump up the "ladder of inference," allowing us better opportunity to look at the data we are dealing with much more objectively than otherwise.

    In so far a looking at medical doctors doing diagnostics - Malcolm Gladwell, in his book "Blink" gave very good insights to rapid cognition and the significant performance improvement in a cardiac care unit in Chicago.

    The crux of the issue is that we as managers are significantly less objective than we really think we are, but we don't realize it and anything that can help raise objectivity and remove bias and preconceived notions will definitely boost performance.
    • Anonymous
    Managers, for the most part, think the same as doctors. Doctors are taught to ask these open-ended questions. However, if their minds are not geared toward really listening to the answers, asking the questions will not help in their diagnoses. Managers seem to HEAR from like gender and like station. They could benefit from observing their medical counterparts.
    • Gerald Nanninga
    • VP, Retail Ventures, Inc.
    A big difference between doctors and managers is the fact that the doctor's patients realize they are sick and proactively seek out the doctor. In the case of a manager, some of the biggest potential problems can come from areas where nobody is complaining. Either the problem is not yet seen, or the people are covering up mistakes to keep their job.

    If a manager waits until the business is sick enough to seek help before acting, that manager will never achieve greatness. Therefore, a good manager needs to get more involved in "preventative medicine," i.e. getting people to live more strategically healthy lifestyles and do periodic checkups to catch potential problems early.
    • Anonymous
    Groopman's book is excellent -- and, bless the man, he writes well. Fortunately, for his book, he was able to talk with doctors who actually REFLECT on their decision-making processes (and mistakes). He also quotes and cites individuals, in the medical community, who have written on medical decision making. In my own experience, I have not found that managers are able to reflect on their own mental processes -- and, therefore, cannot "correct" errors or biases. (Indeed, there is a certain amount of pride in having certain biases -- as in the bias for action!) Certainly, we can learn from observing our medical counterparts. We could also learn from rereading Senge on mental models, or, for that matter, by reading any number of excellent analyses of the Challenger disaster. The key is wanting to learn -- being able to reflect on our own mental processes.
    • Anonymous
    We have to keep in mind that the medical profesion is one of the few were 2+2 most of the time does not equal 4; doctors have to establish a rapport between the patient and them in order to understand what is going on; believe me, I know having been married to one for 34 years.

    The main problem management has, is that many times it does not establish this rapport between the different levels and/or departments in an organization, leading to more or less "I do what I have been told to do and do not get in trouble". Also many managers force upon their subordinates what, how, and why they have to do a task in such a way. Globalization, specially in U.S. companies, has brought forward the "do it this way because I say so, and besides if it works in the U.S., why shouldn't it work everywhere". These people do not take into consideration the different cultures and attitudes existing in the globalized world.

    If you look at corporate policy as a framework within which objectives and strategies are defined, but with enough latitude for each country, division, group, etc to adapt these strategies and objectives to their environment, you are introducing a high element of risk and uncertainty. But at the same time you are empowering those individuals to obtain results as dictated by the objectives, which in the end will most probably conclude with a better working environment and a more successful company in any way you measure it.

    Of course, we should never forget that training your personnel on a continuous basis is a very important part of this development.
    • E. Hassen
    • NHS
    Diagnosis is complex and inductive rather than deductive. The list of all possible diagnoses is long, much longer than one person can know. In seeking diagnoses, clinicians are looking for an action path: to prevent, treat, mitigate, palliate and/or prognosticate. Treating and healing are different things and sometimes simply naming a problem is enough for a patient.

    What can managers learn? Not all things are knowable; not all things are fixable; humans are finite. Logic does not serve and experience always counts. All acts involve trade-offs, costs and benefits. And judgement is very fragile.

    None of the above is actionable.

    So, the essential lesson is this: life is uncertain, still you must act -- in humility -- because you are likelier to be wrong than right. Act and reflect. Outcomes direct actions, but intent is paramount. As Musashi observed, action is distilled intent.
    • Stephen Fister
    • Adjunct Professor, HACC (Harrisburg Area Community College)
    Wonderful observations! I do believe the model could be very successfully used for any management role. With over 50 years in corporate and retail management, I have seen the scenarios many times. We hear the first part of the problem/situation and are already responding before we have heard the rest of the story. Too often we forget that the Lord gave us 2 ears and only one mouth. And of course, many managers just like to hear themselves talk.

    Everyone thinks their time is more valuable than anyone else's. And of course there are the cell phones, pagers and Blackberries.

    The only problem I see is that the people who need to read this type of book never will.
    • Bill Welter
    • Managing Director, Adaptive Strategies, Inc
    There are significant similarities inasmuch as all humans are subject to the same biases and traps. However, the context in which we work is also a significant factor. Consider the basic cycle that all thinking professionals (doctors and managers alike) should use: to sense; to make sense; to decide; and to act. If the professional sees her/his "job" as "getting it done" then they see the world through the lenses of decide and act.

    When that happens (and it happens all too often in a "lean and mean" oprganization) the professional -- doctor and manager alike -- is much more susceptible to the traps waiting for all if us. Unfortunately, too few of us deem "thinking" to be real work.

    By the way, I'm the lead author of "The Prepared Mind of a Leader" (Jossey-Bass, 2006) and I conduct workshops for business managers re: "thinking better." Groopman's book hits the nail on the head and is one of my recommended readings for my clients.
    • Alan Chilcott
    • Managing Director, Oxoid NZ Ltd
    Dear Jim,

    Thanks very much for the thought provoking article!
    The brilliant diagnoses provided by Dr's are most often backed up by the Medical Laboratory Technologists and Technicians. In some instances the Dr is only responsible for a "fishing expedition" and it's the careful diagnosis of laboratory staff with the aid of the clinical details who provide the actual diagnosis.

    In my personal opinion, Medical Laboratory Technologists are extremely diagnostic in their approach to tricky problems, perhaps something could be learnt by studying how this group of people have become such good problem solvers?
    • Mohd Ramlan Mohd Ali
    • Operation Manager, Pos Malaysia Berhad
    How a manager thinks depends on the filter that is filtering information in and out of their brain: their level of knowledge and know-how, skills of interacting with others, analyzing situations and problems, and finally making vital decisions out of it.

    Important decisions still rely on the basis of making such decisions, the principle behind the decisions, and the objectives or goals the decisions are aiming to achieve.
    • Radhakrishnan
    • Business Analyst, WLI
    Good thought. Perhaps, good listening skills and analysing are what that is required for a manager.

    Moreover, the EQ plays a strong part in any manager's ability to assess any situation or person, right?
    • Shaiful
    Of course we could always learn from our medical counterparts in every aspect of our life especially in respect to decision making arts and skill. This is because they are naturally dealing with the most precious souls on the planet earth almost every day (if not every minute or second).

    Relatively, the level of patience required for waiting for the result in particular could be higher for managers compared to doctors. Doctors deal with a lot of pressure to make decisions within a very short timeframe, especially in dealing with patients in wards because they see each other every day and in some cases within minutes, critically. The nature of the harsh environment surrounding the doctors pushes further on doctors to make wise decisions. Hence, our medical counterparts could be good case studies for managers to make wise decisions but in the more prolonged version.
    • Akhil Mehta
    There is a key difference between how a doctor works and how a manager works...and the difference is due to the fact that human life is almost never involved in managerial decision making.

    How so often we have come across business managers and leaders who would rely on what they call instinct or gut feeling to take a decision, backing it up with "in case of failure the responsibility would be ENTIRELY mine". A doctor simply can't have this "privilege"!

    But yes on another plane, a manager has to behave just like a doctor ... in fact, good management consultants do absolutely that: diagonising the problem in a systematic, step by step process, which obviously would take time but ensure that all the facets have been grasped. And it also should include stepping back, and accepting it, when you are not the best person to solve it right!
    • Narendar Singh Raj Purohit
    • Assitant Manager-Institutional Service Delivery, MetLife India Insurance Company Pvt. Ltd.
    Doctors really don't have think strategically like managers because in the case of a "Doctor's Thinking," a patient's life is at stake whereas when a manager decides something it is about what effects the business, its technology & the process. Doctors have their own way of thinking & their own process of going through the thinking, as they work on empirical theories which in part they have learnt from practices adopted by their own superiors. But at the end of day they have to decide on what decision & treatment will bring the patient to better health. Similarly, several managers go through the entire process of thinking but eventually have to decide what is good for business rather than for an individual.

    A sports team captain managing a team of 10 wins the toss but takes a wrong decision that benefits the opposition; this is very much related to some managers taking decisions that have been dubious for the company. As we have heard umpteen times, miscommunication is the result of most failures if not all. It's appropriate to say that if some successful doctors have worked hard for "patient activation & engagement," then some brilliant managers have done exceedingly well when they have engaged their own people into something similar, bringing out ideas & creativity that will have strategic implications on the organization.

    And, the very fact that they are successful is because this form of Patient/Employee Activation & Engagement has resulted in better communication. The process of thinking & decision making does not stop, as situations in an organization change every day. Similarly, cases in the hospital change every day. This is what allows them to think differently.
    • Anonymous
    I have often been disturbed by how often my doctors seem to jump to diagnoses without asking what I deem to be enough questions to ascertain what precisely is wrong. Now, I know this sounds like second-guessing the expert: after all, patients aren't supposed to be in a position to diagnose themselves. However, in a recent case, I had taken the time to research my symptoms on the internet: they could be caused by more than one ailment. Because I knew what I'd been going through, it was obvious to me which it was.

    On telling the doctor my symptoms, he immediately started writing a prescription -- for the wrong ailment. I gently filled in his knowledge of the case history by volunteering more information that I knew would be relevant. He realised my symptoms were caused by another ailment, and immediately changed his prescription.

    It's certainly not about knowing more than your doctor. If he'd bothered to ask more open questions, he would have elicited the information needed to make a correct diagnosis. But too often, doctors seem to believe they can diagnose by ESP. It puts responsibility on the patient to inform the doctor fully, which is wrong, because the patient simply isn't equipped to know what information is relevant.
    • Richard Kunjawa
    • HR Manager, Illovo Sugar Ltd - Dwangwa
    I agree with Groopman's findings that doctors 'most of the time' are more patient when diagnosing people with less serious illnesses. I think their condition is conducive for getting more insight into their problem thereby offering them good treament. But doctors rush when the illness is serious in an effort to save life and in so doing they miss it.

    In the same way, managers when faced with little time and pressure to get things done, fail to think well and so make poor decisions.
    • Margie
    • Lecturer, BK School of Busines Management
    Well, diagnostic exercises are for "problems" or illnesses, dominated by the basic question "What is wrong here?"

    But managers also perform one more critical function -- creation of opportunities. To me this seems to be posing different challenges than those posed by problem solving.

    Nevertheless, management is an eclectic field and how doctors think might, if nothing else, as it appears from Prof. Heskett's description, only confirm what we already know as errors of decision making.
    • Joe Schmid
    • Managing Principal, Oak Leaf Consulting, LLC
    Both medical doctors and organizational managers work in cultures that are historically problem definition poor and solution rich. Their individual rewards systems are both driven by "throughput." Both doctors and managers working in their respective environments have a predisposition to be too fast to action (a valued attribute) and too long protecting their decisions (being wrong has negative connotations).

    Dr. Groopman's point is to know and understand your patient. Develop the context to see the significance of the symptoms. The parallel is true for organizational managers.

    The lesson for both is take the time to get the problem defined correctly if you want to improve the outcomes. If you get the problem defined right up front, you are better able to choose from the vast and rich palette of solutions that are available, and increase the odds of a favorable result.
    • Sandeep Sreedharan
    • Principal, Nihilent
    The human body has always been known to be unpredictable; hence the doctors' dilemma "Symptoms vs Real Problem." The same applies to business. If we have the right approach in identifying the real problem rather than taking decisions based on the symptoms, uncertainty can be mitigated.
    • Bill Ralston
    • PGO Consulting
    The medical world provides excellent metaphors to the rest of us trying to understand decision-making under uncertainty. That's because all of us have experience and can relate to the circumstances of medical diagnosis, treatment, and follow up, and the typical circumstances of doctors treating patients provide great insight on uncertainty and why it must be addressed.

    Also, I'm a little tired of the Cuban Missile Crisis being the primary case for studying uncertainty and decision making in a chaotic environment.

    However, while medical examples are good for showing what uncertainty is, the medical world is relatively behind in putting decision-making under uncertainty solutions into practice. While there are many brilliant doctors and care-givers that practice decision making under uncertainty exceedingly well, having developed their skills and approaches through practice over time, there are many more that don't, and there are few mechanisms in the medical profession for remedying the situation.

    If anything, the medical profession could learn much more about the decision-making processes from the military profession or the services industry. The doctor-patient (customer) interaction, situation analysis, treatment and care design, execution, and follow-up are quite similar to many military-tactical or customer-service situations.
    • CJ Cullinane
    The concept of people, be they patient or employee, holding back information either knowingly or just forgetting, is a problem that can kill a patient or a company. I feel (I have not read the book, but will) that in many situations the patient/employee is not given an opportunity to say what they feel,and I believe this is a huge problem for business.

    How often do we hear stories of employees afraid to tell the BOSS what is really happening at their organization? I remember a few times were I did not speak out concerning a problem because I knew what the boss/shareholders wanted to hear and knew his/their reaction if I did come out with what I really felt concerning an issue.

    How do we get people to open up and say what is really going on? I ask, "What is your biggest problem today?" and then delve into the employee's answer. Often you have to ask this question for a few weeks until the employee tells you what they feel. The wait is worth it!

    I think a bigger problem is the person who does not go to the doctor because of fear of "what they will find." I know more of these people than I do people who have been misdiagnosed. But for the people who do visit the doctor the open-ended questions may be the best.

    Yes, I do believe we managers can learn from doctors. They have to be decisive and react quickly in many situations, and in medicine and business indecision kills.

    (I will definitely read this book!)
    • Fernando das Neves Gomes
    • principal, independent
    We have to constantly look for new technical procedures that can minimize costs and maximize production. In the same way, to improve quality and innovation of products and services we have to constantly improve actions that maximise productivity. We need an ideal read of the market to make acquisitions and fusion actions at strategic moments.

    We also have the big picture. For sales improvement we can give some standardized answers like marketing and communication force improvement and innovation, but to do that we need a constant feeling of the market trends and expectations that do not come from books.

    Concluding, I think that the work of a leader is a little [less] difficult than a doctor's job, because the doctor's work is based (in large part) on unfamiliar diseases and pharmaceutical investigation.
    • Muhammad Awais
    • Product Manager, Cirin Pharmaceuticals
    No doubt a manager also has to play an important role of a doctor who diagnoses the problem in depth and takes the corrective measures to keep the working conditions and ultimately performance smooth. In my opinion the job of a doctor and a manager resemble each other in many aspects, because both have to go through the critical decision making process. A right and timely decision saves the patient's life as well as the bad performance in organizations. So I think the book "How Doctors think" will be of great help for the managers too.
    • Shrikant Sortur
    • Lason, Inc
    Jim: Interesting article, observations and questions. Equally interesting discussion.

    Reminds me of a story I heard some time back.

    A car mechanic was working on a Volkswagen when he spotted a well-known heart surgeon in his shop. The mechanic shouted across the garage: "Hey, Doc, can I ask you a question???" The surgeon, a bit surprised, walked over to the mechanic. The mechanic straightened up, wiped his hands on a rag and asked: "So Doc, look at this engine. I open its heart, take valves out, fix 'em, put 'em back in, and when I finish, it works just like new. So how come I get such a small salary and you get the really big bucks, when you and I are doing basically the same work??"

    The surgeon paused, smiled and leaned over, and whispered to the mechanic .. .. .. "Try doing it with the engine running !!! !!! !!!"

    I think there is a key lesson in the story when we are trying to answer "Can we learn about good (or bad) diagnostic procedure by observing our medical counterparts? What do you think?"

    For sure we can learn. From the brief discussion, it looks to me that the book, "How Doctors Think" by Jerome Groopman, is very interesting and makes some very apt points. But then at the end of the day, the answer to question "How do managers think?" is diverse, complicated and situation specific. The journey is far more enjoyable than the destination. We may never come up with the right answer for every situation.

    As an example, with his bestseller "Blink," Malcolm Gladwell pointed out the great benefits of "thinking without thinking." It was again for specific situations. The book also told the reader when instincts can fail a person. A wine tasting expert can rely on his first impression to tell you the difference between two wines. That comes from years of practice, though. If a novice attempted to do the same, the results would be random and guesswork. The same would be the case with doctors and managers. As human beings we do not have the benefit of hindsight. Decisions that look great could well be a disaster in another situation, and vice versa.

    Sure, managers can learn about good diagnostic procedure by observing medical counterparts, but the key is about applying the right procedure to the right problem. That is where "thinking" matters. Learn, Think and Apply: The outcome will tell you if the thinking was applied in the right way.
    • Todd Rhoad
    • Senior Program Manager
    I'm not sure that managers think like doctors. There are a couple of critical differences between the two professions. First, doctors, similar to engineers, are trained troubleshooters. It takes many years to learn to operate using such a scientific method in solving problems. This is not an easy thing to pick up through experience. A thorough understanding of such systems requires meticulous analysis.

    Managers focus on making decisions with little information, not through a rigorous review of the details. Managers don't receive such problem solving training. There are no sanctioned training requirements for becoming a manager (i.e. required college degree or other intense training). What if doctors, lawyers, engineers, etc. were the same way? Would you trust their advice as much?

    Secondly, doctors are part of a service organization. They make decisions that serve the best interest of their customers. Managers, for the most part, are part of an internal organizational structure where they are commissioned to make the best decision in the interest of the shareholder, leaving those they manage to live with the outcome. Their motivation in solving problems can be quite different.

    In developing AI, engineers studied a great surgeon to understand how he solved difficult brain injuries. What they found was that he thought of all possible solutions, then worked to disprove them one by one until one remained (i.e. the best possible solution). Doctors have the ability to utilize research to improve their problem solving and their understanding of the human body. It is a requirement of the profession. Doctors utilize study and experience to improve. Not so much for managers. They learn from experience rather than the study of others.

    As always, there are things that can be learned from such studies. The only problem is that managers aren't known for their ability to incorporate research and academic-type studies into their organizations. Too many times I've heard others say that "it's nice but not applicable to the real world."
    • michael webster
    • lawyer,
    1. This may be an interesting book.
    2. Most people will not have time to read or digest it by May 23rd.
    3. The deadline for comments is May 23rd.

    Conclusion: [Fill in the logical implication]
    • Raj
    • Software Engineer, xyz
    The ways of thinking of a manager and a doctor are relatively the same based on their experience at work and intuition. The managers additionally would require policies, situational strategies, and their experience. What a manager can pick from a doctor is only the quickness of decision making; and the rest is left untold as it will be unique for each company to perform on its own.
    • Wally Bock
    • Three Star Leadership
    When I researched top performing supervisors, I studied supervisors who were rated excellent by their boss, their peers, and their subordinates, comparing their behaviors with those of their less effective peers. I discovered that the top supervisors used the same heuristic in making decisions about how to deal with behavior/performance issues.

    The heuristic involved asking two sets of questions. All the top supervisors asked the same two questions in the first set. They wanted to know whether the person was able to perform the specific task involved and whether the person was generally willing to pitch in and work.

    Our top supervisors used the answers to those questions to make a basic decision about what to do. Then they asked a second set of questions that varied a bit from top supervisor to top supervisor, but served to decide whether the basic decision should be modified due to the details of the particular situation, organization, etc.

    Their less successful peers treated each performance issue as if it was unique. They had no standard procedure for dealing with a class of problems. As a result they took longer and were often less effective.
    • Anonymous
    In my experience, managers think in terms of what immediate crisis needs attention and what people, in their perception, best fit the criteria to get the job done. Instead of putting to use existing talents in the proper position, they train the people THEY WANT in the "hot" job. This accomplishes two things: 1) Training hours look good for that manager; 2) They get the people they can manage (manipulate) where they want them. What do the employees with that particular talent get? The world may never know.
    • Pallavi Marathe
    • System Engineer, IBM Global Services, India
    That was an amazing article on doctors and their thought patterns. I believe that managers have a different way of thinking (which they do, very hard). The doctor will aim at the person and his/her well being, while the manager has to look at a larger perspective. The manager needs to take care of the health of all his people; and that said, at times, to cater to one person's need, he may have to kill another one's desire, for the good of the organization.
    • Caroline Lee Bivona
    • Accountant
    It is always a pleasure to hear about new perspectives that evolve from the identification of cross-industry patterns. I would also be interested in hearing how other professionals think.

    In my finance and accounting role, I, for one, would be extremely interested in peering into the mind of an engineer--primarily with the scope of seeking ways of eliminating error in my work and the work of the department and also with the purpose of seeing design implementation techniques with the intent of using the knowledge for business planning and procedural development.

    My interest in engineering comes from a fascination of the mind of my key mentor, my dad, an engineer, entrepreneur, and investor.

    One thing about his mind that I know for certain is that he is an excellent listener. What an admirable trait.
    • Cristian Nusimovich
    • Business Unit Manager, BGH S.A. - Argentina
    Doctors, as well as managers, can have a tough time making calls in "unknown territory". They both find their comfort zone in what the author calls "stereotypes" and in what I call past successes, while decisions have to be made looking at the future, not the past.

    It's obvious that discomfort will cause bad calls, since "you want to get it over with," while "your personal favourites" will get a high target ratio, since you are willing to spend time and resources investigating, doing focus groups, hiring external consulting, and so forth.

    The article's a bit disappointing in that the conclusions are kind of obvious.
    • John McKnight
    • Engineer/Manager
    Decision making involves the bringing together of two basic types of information.

    1. Diagnosis ... understanding the situation, analysing it meticulously to define the 'situation'.
    2. The resources in terms of materials and knowledge it takes to intervene in the situation. This is the capability immediately at hand and the availability of outside resources.

    The decision is how to use the resources available or the cost and time to obtain outside resources in order to affect the situation. It requires judgement and experience to understand the effect of applying the resources to the situation and predicting the effect on the situation.

    "A good decision" is the one of applying the least amount of effort to achieve a reasonably acceptable result. That requires a thorough understanding of the situation and resources available ... knowledge.

    It looks simple from the outside.
    • Joanne Celens
    • CEO, Synhtetron
    I did only read the article and was struck by the paragraph on listening as a key success factor: "patient activation and engagement" "by asking open-ended questions whose purpose is to engage patients."

    It is exactly this open listening and engaging of employees that gives managers the input of the "wisdom of crowds."
    While this listening used to be a very labour/time intensive (managing by walking around), it is no longer so today: managers have modern tools available to efficiently listen to crowds.

    From our experience the key success factor is - like with doctors - the management's willingness to hear - this is - to use the "output from the crowds" as input in their decision processes.

    Joanne Celens
    CEO Synthetron
    • William James Dorman
    • Principal, Dorman Mgmt Consulting Co
    Interesting to make analogies, but the basics of medical decision making are grounded in scientific fact whereas there is no unified body of knowledge based on science for the manager. Of course there are broad management princples e.g., span of control or broad methodologies such as decision theory or operations research, but good managers rely on policy, cost of the decision, and ROI. The ingredients of the decision, however, are based on experience and individual intellect.

    I have to add, good managers also obtain input from others in their organizations including employees, whereas the doctor typically does not have time when confronted with a patient who "needs" an answer right now. Most doctors I know never say, I'll get back to you on that!
    • Arbind Sinha
    • Regional Manager, Intense Technologies
    It is a good initiative to talk about a learning relationship between a doctor and a practicing manager. I believe you always learn throughout your life by one or another situation or person. So what if that is coming from a process of a practicing doctor. This will make life much simpler and easier for the practicing manager.

    If you look at the day to day activities of any managers, they have to manage well defined processes and management principles; most of them, I believe, are based on some finding in an ideal situation i.e. a laboratory environment. But in real situations and people, what is involved is totally different e.g. you have to deal with a given situation and at the same time the aspirations and ambition of people. So you can imagine how difficult is to manage everything for a practicing manager.

    So, I see learning for practicing managers not only from doctors but from other professions, too. This will help an organization to a great extent in managing all aspect of human behavior and management issues.
    • Anonymous
    Donald Schon in the "Reflective Practitioner" raised the question of how professionals think in action some time ago. I think it possible that the diagnostic approach of a doctor may have some value in helping the manager, but I am not sure that this is offering something that has not already been said: Could it be old wine in new bottles? Nevertheless, it's worth a read to see if any additional insights are forthcoming.
    • Anonymous
    This is a great combination of a doctor's work with a manager's work.
    • Alberto Souto
    • Consultant/Professor, Buenos Aires, Argentina
    Congratulations to all of you! It's an excellent subject and comments. Unfortunately, I have not read Groopman's book but since I have been working as a manager in the health field I would like to share some comments with all of you.

    Both medicine and management are socio-technologies (as Bunge at McGill pointed out) plus art. The problem arises in the equation when art overcomes technology. There is still a lot of craftsmanship in these two disciplines that should be guided in the right path. Physicians started the trip some years ago with the evidence-based-medicine movement proposed and disseminated by McMaster University in Canada. On the other hand, Professors Pfeffer and Sutton in their recent article "Evidence Based Management" (HBR January 2006) ask why managers do not use facts about what works instead of using partial remedies and untested management miracles.

    Also, the excellent work of Nobel Prize-winner Professor Kahneman and Professor Tversky has invaded our lives with all kinds of heuristics and biases through experiments that, now, are surpassed by the advances in neurosciences with a lot of new evidence of how our brain works, showing how the framing effect is related to the amygdale (a specific part of our brain). Therefore it seems like a decision should be studied from a bio-psycho-social perspective.

    Finally, I think we (physicians, managers, professors, students, etc.) are all humans that ignore more than we know. More than Homo sapiens we are Homo insipiens, who just ignore?
    • Yesha
    Well, I think it's all about asking questions that cater to a maximum of different directions in order to get desired positive results.

    It can address the profession called medical science or business management. Doctor or manager hardly matters.

    The book is more or less about where people can go wrong in the practice of medical science. Same way, books are there and more will come from different fields.

    The important thing according me to is be aware, be sensible, be yourself! That's it! :-) The rest will always follow.
    • Mohandas Nair
    • Educator, Self-employed
    Managing is something we are doing all the time and have done since we were children. Our learning and experiences influenced how we thought, felt and acted, and continue to do so. Some major experience has to occur if we are to think and act differently. Thus, the manager's thinking is an output of his/her experiences and will always be unique to the individual.
    • Siva Subramaniam
    • Consultant
    A doctor (generally though not always) actively listens, absorbs the facts, and acts on the patients' needs that best alleviates the patients' present condition to a best possible outcome. A manager usually analyzes, adapts, and then aligns actions to the most optimal results. The metric for measuring the doctor's work is a near perfect solution while the manager has to deliver the most effective outcome vis-a-vis original plans. Although there are important nuggets to learn from the physician's professional practice, a manager could in several cases be chasing the wrong mountain if tailoring a perfect platform results in hindering the final end goals.

    The innate ability to "watch from the balcony" while also managing the work given is a hard-to-grasp skill that managers for the most part do not have in a work environment geared towards business results. I'd like to say that Dr. Groopman's treatise adds a critical link to the thinking behind actions of the various medical professionals in the discharge of their duties and helps the managerial community to learn from and share with their physician colleagues.
    • Darryl Duncan
    • Manager
    One of the early comments (#9) suggested that doctors perhaps have it easier than managers because patients self-identify, whereas employees sometimes cover up or are unaware of their mistakes. This comment caught my attention for two reasons.

    First, while doctors likely have to deal with the issue of patients covering things up--what I call the "I didn't think you needed to know that" issue--less often than managers (the patients have already brought themselves to the doctor's office, after all), I expect the consequences of a doctor failing to surface this additional information is more significant for patients than it is for employees. (Although, ultimately, the result is the same: the patient expires and the employee is fired.) I wonder what techniques successful doctors use to bring these hidden bits of critical information into light.

    Second, managers regularly have to deal with the "I didn't think you needed to know that" issue. I wonder what techniques managers are using right now to surface these issues (beyond regular performance reviews, open communications and m-b-w-a) and how closely these mirror those used by doctors.

    In the end, I'm left thinking about "symptoms" and self-identification by employees. I wonder if we do a good enough job of educating our employees to recognize symptoms of "poor health" so that they are able to self-identify themselves to their managers.

    A final word on the comments made suggesting that doctors and managers work towards different end-goals: Doctors work towards keeping the patient healthy, just as managers work to keep their organizations healthy. In protecting the patient, a doctor will sometimes have to cut out a deficient part of the body. In protecting the organization, a manager will sometimes have to remove an employee. Let's not confuse the manager's primary responsibility to the company with a responsibility to make every employee happy all the time.
    • Ulysses U. Pardey, MBA
    • Managing Director, Am-Tech, S.A., Panama, Rep. of Panama
    We managers essentially manage people, things, time, and any combination of these three. It is also a fact that we deal with healthy employees. ... Let's consider for the sake of illustration some real situations in both professions:

    It is true that when a customer gets in a store, the salesperson is expected to provide him/her with information about the product or service. This customer has the right to leave without paying for anything whether he/she was pleased with the information or the product/service.

    When a patient goes to a doctor because he/she feels sick, the doctor provides the patient with information, and generally speaking the patient is expected to pay for it whether or not he/she then buys the prescription in a drugstore. The doctor is not questioned most of the time. ...

    However, I am sure that we managers can and should learn from doctors. Doctors as well as engineers acquire their knowledge by doing. For instance, undergraduates can legally study dead bodies to learn how the body works. And later, future doctors can legally continue learning with real live patients in hospitals. They are in real contact with what they must understand. There can be immediate learning based on cause/effect.

    While studying business management we don't have access to "dead" and live companies in order to understand how people, things, and time act and react in a real-life business setting. In the best situations, we have case studies. They lack this short-term, real-life setting feedback that is so useful for enhancing accurate understanding.

    I tend to believe that this is where we managers could learn a great deal from doctors. The ways and tools used to teach and understand medicine allow doctors to be hands-on today with what will be their job tomorrow. They experience and acquire practical understanding by doing it with real live patients when still students. Will future managers have the privilege to experience and acquire practical understanding within real-life companies whose one and only purpose is to be a complementary device to business school teaching and learning? It is just a matter of time before someone turns this initiative into a valuable means, and I am sure HBS can take the lead. Best wishes.
    • Prof. K. Prabhakar
    • Director, KSR College of Technology
    The decision making of doctors has been studied from the point of view of medicine as practiced in western countries. The decision making by doctors from Aurveda (Indian Medicine) Siddha or Tibetian medicine is totally different. Therefore generalizing decision making of doctors based on one system of medicine may not be a right thing according to me.

    Doctors, based on their experience, develop certain hypotheses that are confirmed by laboratory tests. There are large support services and economic units such as insurance and other issues taken into consideration by doctors. On the other hand, if there is no diagnostic lab and decisions have to be made on the basis of observation and the lifestyle of the patient, as happens in other types of diagnosis, the decision making will be totally different.

    However, the role of intuition in the decision making of doctors and the tacit knowledge that is developed by them over years of diagnosis of patients also plays a key role.

    Now, based on this discussion, if you examine decision making by doctors:

    1) He depends on his knowledge
    2) Obtains information by questioning the patient
    3) Uses appropriate diagnostic tools to confirm his diagnosis
    5) Based on the seriousness of the disease he may control all external variables and may confine the patient to hospital
    4) Prescribes medicine
    5) Gives a prognosis.

    If we examine managerial decision making, a manager operates in an environment where the number of variables that is controllable is limited. While a doctor can control a maximum number of variables, that affects a patient. This degree of freedom to control the external variables as well as being in total control of a patient's will to comply with instructions is not available to a manager.

    Though it may be useful to study doctors' decision making, the degree of controllability and compliance by a patient may not be an analogy to managerial decision making. However, the role of intuition, tacit knowledge, and ethics in decision making may be studied for commonalities.
    • Isaac
    • Internal Controller, M (M) L
    Managers don't think like doctors, they have different modus operandi and work ethics. Managers can use the "FLIP FLOP" tool and any other bias in business while doctors can't. Managers must destroy to reinvent while doctors must save lives and give hopes. Reasoning from analogy.
    • Deepak Chauhan
    • Consultant
    Excellent commnets, I thank everyone. I have not read Groopman's book but since I have been working as a consultant and managing a team, I do believe that a manager and a doctor's profession is similar in some kind of situation because both of them have an aim: to resolve the problem and come out with a solution and be ready for the future (known & unknown).

    There are several points that makes these two professions diffrent from each other. The art of decision making for doctors is very quick but for a manager will be slow because they need to follow certain rules, regulations, policies & procedures.

    Why there is quickness in a doctor's profession is because they are directly in contact with the party (patient) on whom these decisions will be implemented. Due to the lack of this kind of relation, a manager needs to consider so many facts & data, because managers' decisions will or might affect more than one person's life in the same situation.

    The scope of decision making is wider in the case of a manager while in the case of a doctor it is narrow.

    I would like to give more weight to the managers' profession as they do not work or serve only to resolve the problem but also to create the opportunity in the company for its external & internal growth.

    I would like to summarize by these words. Both of them are working towards a common goal: doctors work to keep their patient healthy and managers work to keep their organisation healthy.
    • Phil Clark
    • Clark & Associates
    I have been teaching a program developed over 35 years of working with people that have to make decisions every day and often in a crisis. I have worked with varied professions. I have found the fundamental decision processes are universal. It is basically a decision process of 7 steps which must be processed through 7 traps. The more you understand these basics the more effective your decision process can be. Does it guarantee perfect decisions? No. What I have also learned is basically there are no objective decisions. Sorry, if you are looking for a totally objective decision ... you are on an impossible mission. You can learn to make better decisions and improve the decisions of organizations. So all hope is not lost.
    • Akram Boutros, MD, FACHE
    • EVP and Chief Administrative Officer, St. Francis Hospital - The Heart Center
    Dr. Jerome Groopman exposes how exemplary diagnosticians make decisions, and offers wonderful insights into the pros and cons of pattern recognition over algorithmic discovery. Much of what has helped me become effective is due to the combination of skills and principles I learned as a physician, manager and (HBS) Advanced Management Program graduate.

    Exemplary diagnosticians do ask open-ended questions. That's a rarity among business leaders. They also prefer to listen than speak. They assign weights to various pieces of information and promote the use of only the tests that will yield the best, not the most, information. They use a rifle rather than a shotgun approach. However, they are more cautious than business mangers, and often less strategic.

    They have many attributes in common with business leaders. Their end goals are similar to those of a business manager: that is, ameliorating the symptoms by treating the underlying disorder. They have an almost endless supply of data, but little time to gather it and make valued judgments upon the data. They have a number of constituencies that answer to the patient, family, payors and their own staff and partners. They have a variety of consultants they can access, but must be careful so as not to abdicate their position as managing the consultants' input for the sake of the patient.

    So with that said, I think what I have learned from being a physician that applies to management is as follows:

    1. Listen to the person who is suffering; they will usually lead you to the origin of the problem and the solution.
    2. Seek both corroborate and contradicting data.
    3. Recognize patterns of effects rather than focus on the immediate symptom.
    4. Invite consultation, but only judiciously.
    5. Make a diagnosis; treat and modify based on the results.
    • Shifan Razick
    • Business Analyst, Q&E
    Well, interesting topic, but the success of organizations depends mainly on innovation, so the lack of innovation focus in medicine shows the difference between two great disciplines.
    • Homer Johnson
    • Professor of Management, Loyola University Chicago
    One should quickly add to Groopman's discussion that doctors can't and don't consider all of the information available in the environment. Rather, they look for patterns. Not any pattern, but patterns that fit their mental models. This point is critical--the environment does not impose a structure on the doctor's thinking; rather the doctor's mental models impose a structure on the environment.

    It is the mental model that makes "sense" out of the patient's symptoms. Moreover, it is assumed that the extent to which the doctors have developed valid and useful models, the extent to which their diagnosis (and treatment) is accurate. Or put more directly, effective doctors have developed mental models that accurately diagnose and treat, whereas ineffective doctors carry around models that are incomplete, inaccurate, or lacking in the depth or complexity to accurately understand the patient's problems.

    Mental models provide the basis for thinking and action, not only for medical doctors, but also for managers. The basis for manager effectiveness is not knowledge, or experience, or the competencies one masters, per se. Rather it is how they think; it's their mental models. I think this has profound implications for developing managers or doctors.
    • Dr. Hemjit Balakrishnan
    • Sr. Vice President - Strategy & HR, Health Prime International
    "How Doctors Think' by Jerome Groopman throws open an interesting paradigm on decision making quite intensively from two aspects of any institutionalized practice both social in nature i.e., organisation and human life.

    Throughout the annals of modern management, decision making has occupied such a wide debate and brought aspects like "Perception and Halo" to guard against any decision based on biases or insufficient data, and goes on to search for more "objectivity" to aid better decision making. Within management the discussion on who is an ideal manager has always revolved around such key concepts as listening, communication, observing, disseminating/gathering data, analyzing, and cognitively interpreting it, which made the father of management, Peter Drucker, write, "Management is not only a science and an art, it is also a craft"

    What holds the key for any successful probing? Diagnosis or evaluation to derive "ideal facts" depends a lot on how one can stay apart from one's own biases and look at issues-aspects-cases as unique to arrive at the best solution. The greatest saying which applies in this context is "to know others is knowledge and to know yourself is wisdom."

    Concepts like re-engineering, re-inventing, and transformation vocabulary have brought managers to think beyond conventional practices or classical approaches to problem-solving and search for unconventional and radical approaches while dealing with challenges (not problems)as transformational vocabulary advocates.
    • Kirk Richardson
    • Applications Development Mgr, Lozier
    Key similarities: doctors and managers often have to problem solve numerous, diverse issues in a given day.

    Key differences: doctors experience higher highs and lower lows, while managers have to serve many more masters - employee, team, dept, company, boss, peers, etc.

    Keys to success:

    (1) Educate your employees/patients that you want to hear their views and ideas -- convince them of this [so it's not] just lip service.
    (2) Be rigorous in your approach to problem solving.
    (3) Truly listen without thinking of solutions while people speak.
    (4) Always go after the root cause, not just the symptom(s).
    (5) Play devil's advocate against your proposed solutions. Really try to find fault.
    (6) Explain your decisions and how you came to them.