Decision making processes in sports and in medicine: refereeing the game.

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. 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. 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. 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.’’ 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. 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. 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