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Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors
  1. Oliver Pumphrey1,
  2. Jack Grenville2,
  3. Matthew Colquhoun3,
  4. Barry Mullins4,
  5. Patrick Earls5,
  6. Simon Eaton6,
  7. Stewart Cleeve7
  1. 1 Cardiothoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
  2. 2 Emergency Medicine, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
  3. 3 Infectious Diseases, Northwick Park Hospital, London North West University Healthcare, London, UK
  4. 4 Orthopaedic Surgery, Poole Hospital NHS Foundation Trust, Poole, UK
  5. 5 Anaesthetics, Whipps Cross Hospital, Barts Health NHS Trust, London, UK
  6. 6 Great Ormond Street Institute of Child Health, University College London Medical School, London, UK
  7. 7 Paediatric Surgery, Barts Health NHS Trust, London, UK
  1. Correspondence to Mr Oliver Pumphrey, Cardiothoracic Surgery, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, UK; oliver.pumphrey{at}


Purpose To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade.

Study design We conducted a cross-sectional survey of doctors of different specialities and grades at St. George’s Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative.

Results We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005).

Conclusions Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

  • medical education & training
  • quality in healthcare
  • health & safety
  • human resource management

Statistics from


  • Contributors OP designed the study, collected data and led on writing the manuscript. JG, MC, BM and PE collected data and contributed to writing the manuscript. SE analysed the data and had input on writing the manuscript. SC had input on study design and critically reviewed the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MC received funding for a separate project from Pfizer.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Full original dataset available on request from the corresponding author.

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