Saturday, February 1, 2014

"Don't Just Do Something, Stand There: The Four Types of Uncertainty

"Don't just do something, stand there!" is a famous saying among surgeons.

Surgeons, inculcated in adhering to that portion of the Hippocratic Oath instructing them to "do no harm", are instructed to think before they cut.   An emergency room surgeon doesn't just begin carving away until she has a more educated perspective on whether it is the gall bladder or the pancreas that has caused this patient to arrive in the emergency room today.  Although surgery of a purely exploratory nature is sometimes required, a key point remains that a critical path towards "doing no harm" mandates informed cutting to the extent practicable, given the current circumstances.

This "don't just do something, stand there!" aphorism applies to foreign policy as well. Presidents from both parties have told us that "doing nothing is not an option" as we hurtle towards yet another military engagement distant from our shores.

This is false. We can indeed include "doing nothing" as an option, and sometimes the most competent approach is to not just do something, but to stand there.

What is it that surgeons do during this period of just "standing there" that precedes making that first incision on the belly of their patient?

One thing they do in these contexts is to systematically reduce uncertainty. Surgeons learn that, even if it is a mystery to the lay person, there are four types of uncertainty.

The four types of uncertainty are as follows:
  • the "known knowns"
  • the "unknown knowns"
  • the "known unknowns"
  • the "unknown unknowns".
Surgeons systematically reduce each of these four types of uncertainty while they simply "stand there". 

Doing so causes them to make more informed decisions, which reduces lawsuits and unfavorable patient outcomes.

Learn to distinguish the differences among these four types of uncertainty. Most of the chattering classes are only aware of the fourth type ("unknown unknowns"), popularized by Donald Rumsfeld.

However, Rumsfeld's problems in Iraq did not arise from the "unknown unknowns". Rather, they arose from his mistakes surrounding his "known knowns", i.e. those "undeniable" facts about which he claimed complete certainty. Rumsfeld's failure to investigate the actual veracity of his "known knowns" was a major factor contributing to the various adverse scenarios that occurred after that invasion. 

For example, one of Rumsfeld's fallacious "known knowns" was the "slam dunk" "objective fact" that Iraq possessed weapons of mass destruction.  Whether this was in fact true was never competently explored, despite having teams of UN weapons inspectors on the ground that would have provided a definitively negative answer, had Bush's emergency surgery upon Iraq been postponed for a few months.

Another fallacious "known known" of Rumsfeld's analytical framework was that the Iraqis would welcome us with flowers and jubilation.  This too was not fact, but rather wishful thinking.

Similarly, President Obama's failure in 2011 to address his "known knowns" at the beginning of the Syrian uprising (such as "we are sure al Qaeda will be unable to secure a foothold in Syria" and "we can trust the Saudis to tell us who the good guys are") substantially contributed to the various adverse scenarios we face there today.

In a crisis situation that may present itself to an emergency room surgeon, focusing on the third type of uncertainty denoted by "known unknowns" is likely the most highly leveraged technique for making informed decisions in a hurry. Systematically and relentlessly reducing the uncertainty surrounding your "known unknowns" can deeply inform your understanding across several axes of description.  If you only have time to reduce one type of uncertainty, it is typically competent to focus on this one.

For example, one thing you may know you do not know (a "known unknown") is whether this patient is a diabetic.  Is there a way to find out through the next of kin?  That may change the probabilities as to whether it is his pancreas acting up, rather than his gall bladder.

Additionally, another "known unknown" to address is whether that patient was on any medication prior to presenting in the emergency room.  If so, he may require a reduction in the amount of anesthesia administered, so that you reduce the likelihood of killing him on the operating table. You know you do not know this. It is a "known unknown". Try to reduce the uncertainty around this "known unknown" and other instances of that particular type of uncertainty while you are "standing there".

Systematically reducing the four types of uncertainty prior to jumping headfirst into a major life decision promotes more informed decisionmaking and better outcomes.

It's what you do while you are doing nothing, just standing there.

Reduce the four types of uncertainty before you insert your scalpel into the patient.

"Don't just do something.  Stand there!" I have found framing my experience as a surgeon, rather than an artist or engineer, to be profoundly helpful.

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