What do great baseball players and cardiologists have in common? Not much, may be your first reaction. However, as I was preparing some comments on the topic of decision making for our clerkship class recently, I came to recognize some intriguing parallels.

baseball1Baseball players come basically in two varieties, pitchers and batters. Pitchers are large, powerful people who stand on a mound of elevated dirt and hurl the ball toward an imaginary area of space 60.5 feet away called the “strike zone”. The strike zone is defined by home plate and, believe it or not, anatomic dimensions of the batter. If the pitcher is able to do so three times, he/she records an “out”, and once sufficient outs are recorded, the game ends. It’s basically that simple. The rest is largely spitting and scratching.

baseball2The objective of the batter is to intercept the ball as it travels through the strike zone. To make this challenging, the batter must do so by swinging an implement remarkably ill suited to the purpose called a “bat”, which is a carved wooden stick barely wider than the ball. To make things even more interesting, the bat has a curved surface, which causes the ball to careen in virtually any direction unless very precise contact is achieved. Batters are also big, powerful people. When they get the bat into the right place at the precisely right time and connect with a rapidly moving ball, the result is a graceful, glorious flight through the stadium and into the stands. They are then heroes and the focus of much jubilation and adulation. When they swing and miss, they look rather ridiculous, even comical, and are the target of derision and amusement from the assembled masses. It’s truly all or nothing.

Now let’s do some simple math. An accomplished professional baseball pitcher can throw a baseball in excess of 90 miles per hour. The ball will therefore reach the strike zone 60.5 feet away in about 400 milliseconds, and will actually be in the strike zone and available to the batter for only about 5 msec. Neurologic activation of the various muscle groups required for the batter to even begin to move the bat takes about 200 msec, and then must be moved through the strike zone. All this means that the batter must commit to swing shortly after the ball leaves the pitcher’s hand. In fact, it’s been estimated that the batter must decide and commit to the swing within the first 100 msec of the ball’s flight. If they wait until the ball is closer, it’s far too late to hit the ball. In short, they must make a critical decision with minimal information, and must commit fully to that decision if they’re to have any hope of getting the ball into the field of play. baseball3There will always be considerable uncertainly (good pitchers can vary the speed and path of the ball), and they must be prepared to deal with inevitable failure. The greatest hitter of all time was, arguably, Ted Williams, whose lifetime success rate was about 40%. Even very good professional hitters fail 70 or even 80 percent of the time. What makes someone willing to take on such a task? What makes someone able to succeed? Much has been written about vision, reflexes, flexibility, swing speed. I would submit that great batters have two key and indispensible qualities:

  • the ability to make and commit completely to rapid, mostly intuitive decisions unsupported by complete information, and
  • the ability to deal emotionally and recover from failure.

baseball4Pitchers must also make decisions, but can control the pace of those decisions. They take time to consider each pitch, often delaying the game by wandering around the mound, rubbing the ball in a contemplative way, “adjusting equipment” and even conferring with teammates. They therefore have the ability to consider their decision, commit completely to that decision, and, only then, execute the decision. In short, they can become sure of what they wish to do and separate the thinking from the execution, unlike the batter who must do both virtually simultaneously.

So what’s this all have to do with Cardiology? When I began my career, cardiologists all did essentially the same things. Today, there are a number of sub-specialties within the field of Cardiology, but they divide basically into those who are primarily engaged in procedural (“interventional” or “invasive”) work and those who are not. Interventional Cardiology, whether it’s coronary or electrophysiologic applications, certainly requires the acquisition of key technical skills. But I would argue that the defining, key characteristics of these folks are their ability/desire/comfort in making critical decisions “on the fly”, often without full information, and being able to deal with sub-optimal outcomes.cardiology1 Those sub-optimal outcomes are fortunately very rare, unlike our baseball-playing friends, but may have considerably more serious consequences. Successes or “home runs” in the interventional world are really the norm, which is wonderful, but doesn’t change the critical nature of each individual decision. “Non-invasive” cardiologists also make critical, life determining decisions but, like baseball pitchers, have the option of doing so at a more controlled pace, and only after accumulating what they consider to be complete information.steth

Cardiology is, in fact, a microcosm of modern medical practice in general. Specialties and sub-specialties vary greatly as to procedural mix, how decisions must be made, and likelihood of dealing with adverse outcomes. As our students grapple with decisions about careers, they seek much information about the various specialties and disciplines available to them, but often pay scant attention to their own personal preferences and attributes so critical to career choice and professional satisfaction. Some key questions for medical students as they consider career options:

  1. How do you prefer to make decisions? Some prefer to gather information, consider alternatives, weigh potential outcomes and come to deliberate decisions, while others are comfortable with (and even prefer) more urgent situations where it’s necessary to make the best choice from the information available at the moment. Disciplines and practice settings differ with respect to the types of decisions that are required or appropriate, and therefore provide opportunities for various personalities. In my experience, students who choose surgical specialties do so early in their medical school experience and seldom deviate. Those engaging Internal Medicine usually don’t come to a final decision until late and only after serious consideration of numerous other options. Hardly surprising.
  1. Do you prefer continuing relationships with your patients, or situational, acute intervention? Although all medical disciplines are centred on the patient relationship, for many these involve problem-oriented and self-limited encounters. The preference for and and comfort with continuing relationships that are central to specialties such as Family Medicine can’t really be learned or acquired through practice.
  1. Are you comfortable with the inevitable adverse outcome that can occur despite what appeared to the right decision, appropriately applied? Every physician must learn to deal with these situations, but not all are able easily to move on without being personally affected, or developing self-doubt that may compromise subsequent performance.

These are personal, intrinsic, “hard-wired” qualities that can’t be learned, trained or denied. The key to making effective career decisions is self-awareness, and the way we make decisions is, itself, a key component of that awareness. Medical undergraduate programs are becoming increasingly aware of the need to provide students with the information and counseling they require. Here at Queen’s, we’re fortunate to have an excellent team in Student Affairs, including Drs. Kelly Howse, Susan Haley and Renee Fitzpatrick, who both develop learning events and meet with students individually to assist with career choice.

So, to get things started, are you a pitcher, or a batter?


Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education