Abstract
Outcomes in healthcare depend a great deal on the quality of decisions made by the people who care for patients. In the early days of cardiac surgery decisions were often made on the basis of authority by surgeons with broadly based knowledge and skill, developed through extensive training and very long hours of work. The philosophy of the “captain of the ship” prevailed. The advent of much greater specialization and the emergence of evidence based medicine have led to a shift to a model of decision making in which expertise trumps authority. There has also been a reduction in the length of hours worked by many doctors, and greater emphasis on involving patients in decisions about their own healthcare. The framework for understanding human error has been refined on the basis of empirical and theoretical considerations, and much importance is now placed on the way in which the system as a whole is designed. Unfortunately the complexity of healthcare today is such that some of its properties are best explained through analogies to chaos theory. Furthermore, empirical work suggests that human beings are clearly strong at recognizing patterns, and are less adroit at analyzing complex and unfamiliar situations from first principles in a short time. It follows that the very extensive experience of some of the older practitioners may have been more valuable in decision making than many of the very reasonable and logical advances that have influenced modern practice.