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has been so hard for Goldman to get his ideas accepted. It doesn’t seem to make sense that we can do better by ignoring what seems like perfectly valid information. “This is what opens the decision rule to criticism,” Reilly says. “This is precisely what docs don’t trust. They say, ‘This process must be more complicated than just looking at an ECG and asking these few questions. Why doesn’t this include whether the patient has diabetes? How old he is? Whether he’s had a heart attack before?’ These are obvious questions. They look at it and say, ‘This is nonsense, this is not how you make decisions.’ ” Arthur Evans says that there is a kind of automatic tendency among physicians to believe that a life-or-death decision has to be a difficult decision. “Doctors think it’s mundane to follow guidelines,” he says. “It’s much more gratifying to come up with a decision on your own. Anyone can follow an algorithm. There is a tendency to say, ‘Well, certainly I can do better. It can’t be this simple and efficient; otherwise, why are they paying me so much money?’ ” The algorithm doesn’t feel right.

Many years ago a researcher named Stuart Oskamp conducted a famous study in which he gathered together a group of psychologists and asked each of them to consider the case of a twenty-nine-year-old war veteran named Joseph Kidd. In the first stage of the experiment, he gave them just basic information about Kidd. Then he gave them one and a half single-spaced pages about his childhood. In the third stage, he gave each person two more pages of background on Kidd’s high school and college years. Finally, he gave them a detailed account of Kidd’s time in the army and his later activities. After each stage, the psychologists were asked to answer a twenty-five-item multiple-choice test about Kidd. Oskamp found that as he gave the psychologists more and more information about Kidd, their confidence in the accuracy of their diagnoses increased dramatically. But were they really getting more accurate? As it turns out, they weren’t. With each new round of data, they would go back over the test and change their answers to eight or nine or ten of the questions, but their overall accuracy remained pretty constant at about 30 percent.

“As they received more information,” Oskamp concluded, “their certainty about their own decisions became entirely out of proportion to the actual correctness of those decisions.” This is the same thing that happens with doctors in the ER. They gather and consider far more information than is truly necessary because it makes them feel more confident — and with someone’s life in the balance, they need to feel more confident. The irony, though, is that that very desire for confidence is precisely what ends up undermining the accuracy of their decision. They feed the extra information into the already overcrowded equation they are building in their heads, and they get even more muddled.

What Reilly and his team at Cook County were trying to do, in short, was provide some structure for the spontaneity of the ER. The algorithm is a rule that protects the doctors from being swamped with too much information — the same way that the rule of agreement protects improv actors when they get up onstage. The algorithm frees doctors to attend to all of the other decisions that need to be made in the heat of the moment: If the patient isn’t having a heart attack, what is wrong with him? Do I need to spend more time with this patient or turn my attention to someone with a more serious problem? How should I talk to and relate to him? What does this person need from me to get better?

“One of the things Brendan tries to convey to the house staff is to be meticulous in talking to patients and listening to them and giving a very careful and thorough physical examination — skills that have been neglected by many training programs,” Evans says. “He feels strongly that those activities have intrinsic value in terms of connecting you to another person. He thinks it’s impossible to care for some-one unless you know about their circumstances