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ABSTRACT The Flexner Report highlighted the importance of teaching medical students to reason about uncertainty. The science of medical decision making seeks to explain how medical judgments and decisions ought ideally to be made, how they are actually made in practice, and how they can be improved, given the constraints of medical practice. The field considers both clinical decisions by or for individual patients and societal decisions designed to benefit the public. Despite the relevance of decision making to medical practice, it currently receives little formal attention in the U.S. medical school curriculum. This article suggests three roles for medical decision making in medical education. First, basic decision science would be a valuable prerequisite to medical training. Second, several decision-related competencies would be important outcomes of medical education; these include the physician's own decision skills, the ability to guide patients in shared decisions, and knowledge of health policy decisions at the societal level. Finally, decision making could serve as a unifying principle in the design of the medical curriculum, integrating other curricular content around the need to create physicians who are competent and caring decision makers.
THE MODERN SCIENCE of judgment and decision making began to emerge in the 1950s, and was thus unknown when Abraham Flexner wrote Medical Education in the United States and Canada (1910).This did not stop Flexner from highlighting the unique challenges facing the physician as a decision maker, as part of his effort to press for requiring some college education as a prerequisite for medical school:
The engineer deals mainly with measurable factors. His factor of uncertainty is within fairly narrow limits.The reasoning of the medical student is much more complicated. He handles at one and the same time elements belonging to vastly different categories: physical, biological, psychological elements are involved in each other. (p. 23)
In this statement, Flexner recognizes two key features of medicine. First, uncertainties are ubiquitous, fundamental, and multidimensional. Second, physicians must (and medical students must learn to) understand, confront, and tame these uncertainties.This activity, broadly termed "medical decision making" by its practitioners, is among the most important in the practice of health care.Although physicians acquire knowledge and other skills during their training and through their practice, the outstanding physician is distinguished as well in...