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Clinical Journal of Sport Medicine:
doi: 10.1097/JSM.0b013e3181fc0a98
Editorial

Decision Making Processes in Sports and in Medicine: Refereeing the Game

Conti, Andrea A MD, PhD, MPH*; Gensini, Gian Franco MD*†; Galanti, Giorgio MD*; Conti, Antonio PhD‡

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From the *Dipartimento di Area Critica Medico-Chirurgica, Università degli Studi di Firenze, Firenze, Italy; †Fondazione Don Carlo Gnocchi, IRCCS Firenze, Firenze, Italy; and ‡Dipartimento di Fisiopatologia Clinica, Università degli Studi di Firenze, Firenze, Italy.

Submitted for publication April 1, 2010; accepted September 12, 2010.

Reprints: Antonio Conti, PhD, Dipartimento di Fisiopatologia Clinica, Università degli Studi di Firenze, Viale Pieraccini 6, I-50139, Firenze, Italy (e-mail: aconti@unifi.it).

Physicians are constantly called on to make decisions regarding their patients in different contexts and with varying degrees of certainty. Physicians are not judges, but they are continually called on to observe, interpret, and make decisions, often in a very short time. Doctors can be seen, in some sense, as referees in medical settings, and the behavior of clinicians may be considered as being similar to that of a referee applying the rules of sport.

In any sport, well-defined rules are necessary and must be applied consistently. The rules of sports often go back over centuries and may be subject to possible variations.1-3 In the past, rules were briefer, whereas nowadays their formulation is accentuated by explanations or, for clarification, by examples. In medicine there are also “rules” that go back in time; they too have become more complex in presentation, documentation, and exemplification.4 The protocols for the treatment of neoplastic diseases that have existed for decades and the algorithms for the management of emergency situations may be considered as medical “rules.” More recently, clinical practice guidelines have been elaborated for a great number of scenarios to provide standardized, although flexible, operational recommendations for the professional behavior of clinicians.5 The majority of such guidelines are oriented toward therapy rather than the diagnostic process-the implication being that a correct diagnosis has been achieved as a result of the application of an appropriate diagnostic process. In medicine, decisional and diagnostic processes precede the application of (therapeutic) management “rules” and are effective only once the correct diagnosis has been formulated; in contrast, in sports, the application of existing rules is contemporaneous with the playing of the game and takes place in “real time.”6

Game rules contain features that may be considered, in a general way, as being “objective” and “subjective.” Objective features reflect those situations, and thus decisions, in which there is no margin of doubt regarding the decision itself-consider the video replay or the automatic fault technology in tennis. Subjective features, on the contrary, involve essentially personal interpretations and evaluations. However, even in the case of apparently objective factors (“did the ball cross the line?”), particularly those based on measurements or visual interpretation, a degree of subjectivity emerges, as when a measurement is performed not by machines but by the human eye, and a decision must result.7 The “decision maker” in this context is the referee.

“Rules” in medicine, like sports, may be seen to possess subjective and objective features. Subjectivity in its broader sense is present in the components of technical ability, human sensibility, and relational competence in all the discernible steps in any clinical decision-making process: the personal skills involved in history taking, the ability to perform a physical examination, and the doctor's capacity to order appropriate diagnostic tests. Objective elements, on the other hand, are represented by the evidence drawn from biostatistics and clinical epidemiology.5 However, just as subjective aspects may intervene in objective situations in sport, so, in clinical practice, elements of subjectivity mediate the scientific data, in that the latter may be adapted by physicians to apply to single individuals and objectively derived scientific evidence has to be shaped to real-world clinical situations. Even when protocols and guidelines are available, therapeutic management requires the careful tailoring of scientific evidence to the complex sociobiological-clinical system, that is, the person-patient. More essential still is the necessity for subjective evaluation, using limited evidence or when protocols and practice-guidelines are not yet available. Decision making in clinical medicine reflects the presence of both the clinician's subjectivity and the scientific objectivity that frequently (but not always) accompanies laboratory or imaging investigations. As a consequence, the decision-making processes in both diagnosis and therapy are particularly complex and multifaceted. From this emerges the continuous interaction of subjective and objective features in medical practice, an interaction that has, as its ultimate arbiter and referee, the physician.

Two specific sport situations featuring both subjective and objective characteristics may be usefully compared with medical practice: the false start criteria in athletics and the offside decision in football.8,9

The former has always seemed an objective criterion; from the beginning, there appeared to be no connection with “the opinion of the referee.” The referee had apparently only to judge if one of the runners sprinted before the starting pistol had begun the race. However, since this procedure involved the auditory system of the sprinter, as well as the visual system of the start judge, the criterion was in effect subjective and so errors could be frequent.10,11 To reduce these problems, an automatic start system was devised, based first on an “auditory reaction time” of 120 milliseconds and then on an “assumed auditory reaction time” of 100 milliseconds.12 Given that recent research demonstrates that the “neuromuscular physiological component of simple auditory reaction times” can be under 85 milliseconds,13 it follows that the objectivity of the rule is based on the subjective choice of a constant. As a result, although the rule is defined in a precise numerical manner, a particular sprinter runs the risk of being objectively sanctioned for a false start if his perception of and response to the gun results in a quicker reaction time. This is a good example of an objective criterion frustrated by a subjective one-in this case, the enhanced perceptual and neuromuscular skills of the sprinter.

An example, in medical decision making, of an objective approach being “frustrated” by the subjective response of individuals (and more generally by the enormous complexity of medicine) is the appearance of the side effects of drug therapy. Even when the physician has applied the best available diagnostic and therapeutic decision-making processes and appropriately prescribes a drug to an individual patient, side effects may serve to “frustrate” the optimal objective professional behavior of the doctor, but also, and most importantly, cause subjectively perceived problems for the patient, requiring a careful reconsideration of diagnostic process and therapeutic practice.4,7

The second example is the offside rule in soccer. A violation of the rule is determined by the completely subjective decision of the referee and his assistants; numerous errors can occur. Many scientific articles have been written in the past few years to explain offside decision-making errors, and 2 perceptual error hypotheses have been advanced: the optical error and the perceptual flash-lag hypotheses.14-19 To eliminate errors in evaluation, the use of video replay, as an objective aid to the subjectivity of the referee, has been suggested. This serves as an example of a growing recognition of the need in (at least some) sports to limit as much as possible subjective interpretation in favor of objective decision making. The ongoing debate on offside evaluation is a demonstration of the widely perceived need for objective determinations and less “arbitrary” decision making in sport.

In medicine, both diagnostic and therapeutic decisions were traditionally taken on an essentially subjective basis. Patients in the past were far less involved in the decision-making process, which was not then based on the best available objective elements, such as scientific evidence deriving from clinical controlled trials and systematic reviews,5,20 but reflected the experience and perceptions of physicians who were considered the only appropriate authority, analogous to the referee in a sports setting. But today, physicians are called on to support their subjective evaluations by incorporating all the available external objective information that surrounds patients and their clinical circumstances. This involves the ability to systematically and effectively collect, assess, and apply scientific evidence so as to ensure that decisions are based, to the extent possible, on documented objective evidence-just as the video replay might support and strengthen the decision of the referee in a soccer match.

Even if seemingly quite different, the decision-making processes in sports and in medicine contain common elements. Although, at first glance, it may seem that many decisions in sport are determined by a completely objective process (the electronic start gun) and that medical management decisions have in the past been based on a more subjective approach (“in my experience…”), both fields present elements of objectivity and subjectivity. Indeed, their fascinating complexity and their similarities reside precisely in their composite nature.

In this third millennium, processes of improvement should be elaborated: in sports, introducing to refereeing, for example, adequate instrumental supports; in medical decision making, developing and applying rigorously developed guidelines aimed at reducing idiosyncratic professional behavior. The evolution of such mechanisms must, however, always take place with full awareness of the composite, subjective, and objective features of decision making to be found in both sports and medicine.

It bears noting, finally, that a referee's decision of an “offside” or a “false start” affects the life of a game. Physicians when caught offside or making a false start in their decision-making affect the game of life!

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© 2010 Lippincott Williams & Wilkins, Inc.

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