Daved van Stralen, MD, FAAP, Thomas A. Mercer, RAdm, USN 

Abstract 

We view and understand the world through our internal logic, both public and private internal logic. The logic of practice differs by the frame of reference – a fixed point or within the flux of events, which can have “cosmology episodes” that collapse sensemaking. We have different perceptions and capabilities from the different reference frames, Eulerian and Lagrangian specificities, Euclidean, and topological spaces. When approaching a situation, all we have is observation, induction, and the capability to learn through action. Because people have limited time and knowledge, they must make inferences from the information they have available. We almost universally use heuristic, subjective approaches for better decision-making for complex, interactive problems and processes. Heuristics work through the nearness of information between the old problem-solution and the new problem, a topological space. In routine operations, we are susceptible to heuristic bias, yet error corrects this heuristic bias counterintuitively. We have found four predominant heuristics that cause consequential bias and interfere with effective decision-making: availability, representativeness, confirmation bias, and over-conservative revision. Motivated reasoning, a fifth bias but not from a heuristic, overly scrutinizes information that conflicts with closely held beliefs. Unless we assume that every word and behavior could instantly be wrong, we can too easily begin treating our treatments. 

Introduction 

Interviewing people for After Action Reports or following a serious event, the authors initially hear stories that don’t match how people act in threatening circumstances (1). The stories only make sense through publicly accepted beliefs, heuristics, and logic. A supportive challenge to the description of their actions, while the authors let the person know they had been in similar situations, quickly changes the narrative to one more consistent with human experience. 

Several areas that a person transforms for acceptability are their private logic, how they learn through action, sensemaking shortcuts, and reason. 

We view and understand the world through our internal logic, both public and private internal logic. Our public logic informs our stories and what we openly expect in a situation. Our intimate explanations to ourselves and a few trusted others come from our private logic. 

This is not a trivial distinction; private logic is quite visible in the first minutes or hours after a tragedy as events expose the raw beliefs of each person. Because we otherwise have no access to people’s intimate internal logic, some behaviors and beliefs may not make sense to us unless we appreciate this private internal logic. One author (DvS) has extensive experience as the first person to arrive at an emergency, observing this change in behaviors and words as family or friends arrive. 

We more easily observe this in the hospital following an accident, such as near-drowning when one parent had sole custody of the child. Within several days a narrative develops faulting the custodial parent. Leigh Aveling, the hospital chaplain, explained how this shatters the family’s dynamics. During the first several days, family or friends enter and gain greater influence. Aveling and the author approached the next drowning admission differently. Within the PICU, they isolated the parents from family and friends, with the chaplain offering spiritual counseling and the intensivists explaining childhood behaviors and accidents. 

After 48 hours, the extended family could visit in the presence of parents. The paternal grandparents openly blamed the mother. The father tenderly placed his arm around her and said it was an accident; no one intended it to happen. He continued defending the mother throughout the PICU admission. The child survived. 

The rules of their narrative affect their understanding of the event as it unfolds, how they interpret the results, and how they tell their story. This is how they explain but also how they understand. We will hear this internal logic and the shift from private to the public when we listen to their description or during an interview immediately after events have occurred. First, they make sense to themselves; then, the story seems to change as they begin to make sense to others. This is not falsity; listen for their internal logic, as it will help explain their actions and how they will act next time. “It is after the fact that we retrospectively begin to attribute specific reasons for the decisions that we made,” Capt. Chesley “Sully” Sullenberger (personal communication). 

Academicians studying the logic of practice from outside the flux and trajectory of events attempt to normalize cognition and behaviors without the necessary access to inner mental states impaired by stress and threat that are manifested as contingently linked behaviors (2-4). Detached observation and identification of abstract properties, necessary for scientific objectivity, conceal the situational reasoning and intent of the operator (4-6). The internal logic of operations that individuals utilize becomes unrecognized and inaccessible (7). 

When unrecognized within a system, this concealment impedes the development of experts (6). The academic focus on abstract properties diminishes or further conceals the development of expert performance which, paradoxically, comes from experience in particular situations rather than abstractions (6, 8). 

Renaud Vidal (9), research engineer, Aix Marseille University, observed the “presumption of logic becomes a presumption of control.” HRO decentralization and distribution of autonomy to field operators can undermine the necessary presumption logic and control. The loss of confidence in the system destabilizes the confidence–cautiousness balance. Bob Bea, Professor Emeritus, Civil Engineering, University of California, Berkeley, maintains a database of over 600 engineering failures and has studied some of the largest engineering disasters in recent U.S. history (10). Bea has also had the experience of a novice placed in a dangerous context. 

“Some of the work we have done has been able to reach [field operators] and capture their perceptions and ideas for improvements = worker/operator empowerment. However, many of my colleagues have used methods and approaches that have depowered the worker/operators because of the dramatic differences in ‘language’ and ‘motives.’” 

Bob Bea, 8/30/2005, personal communication

The unsupported belief that objectivity and distance from practice outweigh subjectivity and proximity can lead researchers, leaders, and managers to consider operators as biased, imprecise, and nonrational. The organization and human practices can then be made more rigorous through scientific knowledge with scientific rationality (4). Rejection of the logic of practice used by operators enacts unrecognized restraints that become visible in a crisis (11, 12), a dangerous form of latent failure. 

Yet within the NICU, the environment can become unpredictable from time compression and abrupt changes in structure. The Neonatologist must work with imperfect information in flux—the internal logic of events changes. Threats impair the mind, which, if unmodulated, can easily become unrecognized and even normalized (13). 

Karl Weick (14) described how these “cosmology episodes” collapse sensemaking and leadership. This occurred even with seasoned wildland firefighters during the 1949 Mann Gulch Fire. Such abrupt breaches in the environment involve the entire group or organization. What is rational and logical in structured, predictable environments becomes harmful during a cosmology episode. Actions or events may appear irrational solely because we do not recognize the system’s internal logic. We likely continue our use of classical, scientific logic even as the system’s internal logic changes. 

This forms a gap between what executives and administrators expect based on concepts and plans developed from public logic and the actual behaviors that emerge from private logic. 

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Conclusion 

We do not give up our judgment and creativity in a dangerous context or lose our thinking under time compression. We can use inductive processes to learn from the environment as we act. We can use heuristics to develop solutions for the embedded, ill-defined problem through vigilance toward error, using error to define our operational envelope (46). Anomalies and disconfirming evidence are valuable; we search for them. Counterintuitively, by constantly proving ourselves wrong, we become closer to being right. 

We do not do this through speed or shortcuts but by increasing our tempo. Boyd described the methods and benefits of a faster tempo: the ability to transition more rapidly than events change, develop more repertoires of action, free and open communication, interactive support, increased information sources to select from, and generation of new ideas that can be rapidly tested (64). Our private logic can then become our public logic. 

“Morally, we interact with others by avoiding mismatches between what we say we are, what we are, and the world we have to deal with,”

John Boyd (64). 

References: 

1. van Stralen D, McKay S, Williams GT, Mercer TA. Tactical Improvisation: After-Action/ Comprehensive Analysis of the Active Shooter Incident Response by the San Bernardino City Fire Department December 2, 2015. San Bernardino, CA: San Bernardino County Fire Protection District; 2018. 

2. van Stralen D, Mercer TA. During Pandemic COVID-19, the High-Reliability Organization (HRO) Identifies Maladaptive Stress Behaviors: The Stress-Fear-Threat Cascade. Neonatology Today. 2020;15(11):113-24. doi: 10.51362/neonatology.today/2020111511113124. 

3. van Stralen D. Pragmatic High-Reliability Organization (HRO) During Pandemic COVID-19. Neonatology Today. 2020;15(4):3-9. 

4. Sandberg J, Tsoukas H. Grasping the logic of practice: Theorizing through practical rationality. Academy of management review. 2011;36(2):338-60. 

5. Dreyfus HL. What could be more intelligible than everyday intelligibility? Reinterpreting division I of Being and Time in the light of division II. Bulletin of Science, Technology & Society. 2004;24(3):265-74. 

6. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley; 1984. 

7. van Stralen D, Inozu B, Byrum S. High Reliability for a Highly Unreliable World: Preparing for Code Blue through Daily Operations in Healthcare. North Charleston, SC: CreatSpace Publishing; 2017. 

8. Dreyfus HL, Dreyfus SE. From Socrates to expert systems: The limits of calculative rationality. In: C. M, A. H, editors. Philosophy and technology II. Boston Studies in the Philosophy of Science. 90. Berlin, Germany: Springer, Dordrecht; 1986. p. 111-30. 

9. Vidal R. Managing Uncertainty: The Engineer, the Craftsman and the Gardener. Journal of Contingencies and Crisis Management. 2015;23(2):106-16. doi: 10.1111/1468- 5973.12081. 

10. Prud’homme A. Bob Bea, the Master of Disaster. Men’s Journal 2013:72-5. 

11. Weick KE. Enactment and Organizing. The Social Psychology of Organizing. Second ed. New York, NY: McGraw-Hill, Inc.; 1979. p. 147-69. 

12. Weick KE. Enacted sensemaking in crisis situations Journal of management studies. 1988;25(4):305-17. 

13. van Stralen D, Mercer TA. Pragmatic High-Reliability Organizations (HRO) Modulate the Functions of Stress and Fear Behaviors During Pandemic COVID-19: The Stress-Fear- Threat Cascade. Neonatology Today. 2020;15(10):126-34. doi: 10.51362/neonatology.today/2020101510126134. 

14. Weick KE. The collapse of sensemaking in organizations: The Mann Gulch disaster. Administrative science quarterly. 1993;38(4):628-52. 

15. van Stralen D, Mercer TA. Pandemic COVID-19, the High- Reliability Organization (HRO), and the Ecology of Fear. Neonatology Today. 2020;15(12):129-38. doi: 10.51362/neonatology.today/2020121512129138. 

16. Price J.F. Lagrangian and eulerian representations of fluid flow: Kinematics and the equations of motion: MIT OpenCourseWare; 2006. 

17. Dewey J. The sphere of application of the excluded middle. The Journal of Philosophy. 1929;26(26):701-5. 

18. Boyd J. Destruction and creation. Fort Leavenworth, KS: U.S. Army Comand and General Staff College, 1976. 

19. Benner P. Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of science, technology & society. 2004;24(3):188-99. 

20. Wolfberg A. Full-spectrum analysis: A new way of thinking for a new world. Military Review. 2006;86(4):35-42. 

21. Weick KE. Ambiguity as Grasp: The Reworking of Sense. Journal of Contingencies and Crisis Management. 2015;23(2):117-23. doi: 10.1111/1468-5973.12080. 

22. Benner P. From novice to expert. American Journal of nursing. 1982;82(3):402-7. 

23. Aucher G. An Internal Version of Epistemic Logic. Studia Logica. 2010;94(1):1-22. doi: 10.1007/s11225-010-9227-9. 

24. Euler L. Opera Omnia, ser. 1, vol. 2. In: Pólya G, editor. Mathematics and plausible reasoning: Induction and analogy in mathematics. 1. Princeton, NJ: Princeton University Press; 1761. 

25. Pólya G. How to solve it: a new aspect of mathematical method. Garden City, N.Y.: Doubleday; 1945. 

26. Nadel SF. The Foundations of Social Anthropology. London, UK: Routledge; 1951. 

27. van Stralen D, Mercer TA. Common Sense High Reliability Organizing (HRO) in the Response to COVID-19. Neonatology Today. 2021;16(7):90-102. doi: 10.51362/neonatology.today/2021716790102. 

28. Sandberg J, Tsoukas H. Making sense of the sensemaking perspective: Its constituents, limitations, and opportunities for further development. Journal of Organizational Behavior. 2015;36(S1):S6-S32. doi: 10.1002/job.1937. 

29. Weick KE. Sensemaking in organizations. Dickens G, editor. Thousand Oaks, CA: Sage; 1995. 

30. Dewey J. How we think. New York, NY: D. C. Heath & Co.; 1910. 

31. Pólya G. Mathematics and plausible reasoning: Induction and analogy in mathematics. Princeton, NJ: Princeton University Press; 1954. 

32. van Stralen D, Mercer TA. The Art of Neonatology, the Art of High Reliability as a Response to COVID-19. Neonatology Today. 2021;16(2):74-83. doi: 10.51362/neonatology.today/202121627483. 

33. Simon HA. The structure of ill structured problems. Artificial Intelligence. 1973;4(3-4):181-201. doi: 10.1016/0004- 3702(73)90011-8. 

34. Simon HA. The sciences of the artificial: MIT press; 2019. 

35. Neth H, Gigerenzer G. Heuristics: Tools for an uncertain world. Emerging trends in the social and behavioral sciences: Wiley Online Library; 2015. p. 1-18. 

36. Simon HA, Newell A. Heuristic Problem Solving: The Next Advance in Operations Research. Operations Research. 1958;6(1):1-10. doi: 10.1287/opre.6.1.1. 

37. Prud’homme A. Bob Bea, the Master of Disaster. Men’s Journal. 2013;5:72-5. 

38. Shannon CE. A Mathematical Theory of Communication. Bell System Technical Journal. 1948;27(3):379-423. doi: 10.1002/j.1538-7305.1948.tb01338.x. 

39. Van Stralen D. Ambiguity. Wiley Online Library; 2015. 

40. Orr GE. Combat Operations C3I: Fundamentals and Interactions. Maxwell Air Force Base, Montgomery, AL: Airpower Research Institute, USAF; 1983. 

41. van Stralen D, Mercer TA. High Reliability Organizing (HRO) is the Extension of Neonatology during Pandemic COVID-19. Neonatology Today. 2021;16(5):97-109. doi: 10.51362/neonatology.today/2021516597109. 

42. Bickhard MH, Campbell RL. Topologies of learning and development. New Ideas in Psychology. 1996;14(2):111-56. 

43. Simon H. The executive’s responsibility for innovation. Chicago, IL: University of Chicago; 1957. p. 4. 

44. Gigerenzer G, Goldstein DG. Reasoning the fast and frugal way: models of bounded rationality. Psychol Rev. 1996;103(4):650-69. Epub 1996/10/01. doi: 10.1037/0033-295x.103.4.650. PubMed PMID: 8888650. 

45. Gigerenzer G. Why Heuristics Work. Perspect Psychol Sci. 2008;3(1):20-9. Epub 2008/01/01. doi: 10.1111/j.1745- 6916.2008.00058.x. PubMed PMID: 26158666. 

46. van Stralen D, Gambino W. Error as a Faulty Failure Signal. Neonatology Today. 2020;15(9):114-7. doi: 10.51362/neonatology.today/20209159114117. 

47. Minsky M. A framework for representing knowledge. In: Winston PH, editor. The Psychology of Computer Vision. New York, NY: 211-277; 1975. 

48. Kahneman D, Tversky A. On the psychology of prediction. Psychological Review. 1973;80(4):237-51. doi: 10.1037/h0034747. 

49. Dreyfus SE, Dreyfus HL. The Scope, Limits, and Training Implications of Three Models of Aircraft Pilot Emergency Response Behavior. Berkeley, CA: University of California, Berkeley, Center OR; 1979 February 1979. Report No.: ORC 79-2 Contract No.: ORC 79-2. 

50. van Stralen D, Mercer TA. High-Reliability Organizing (HRO), Decision Making, the OODA Loop, and COVID-19. Neonatology Today. 2021;16(8):86-96. 

51. Tversky A, Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science. 1974;185(4157):1124-31. Epub 1974/09/27. doi: 10.1126/science.185.4157.1124. PubMed PMID: 17835457. 

52. Tversky A, Kahneman D. Judgment Under Uncertainty: Heuristics and Biases. Springfield, VA: Oregon Research Institute, Advanced Research Projects Agency OoNR; 1973 Contract No.: AD-767 426. 

53. Boyd J. A discourse on winning and losing. Maxwell AFB, Alabama: Air University Press; 2018. 

54. van Stralen D, Mercer TA. High Altitude Climbing, High Reliability, COVID-19, and the Power of Observation. Neonatology Today. 2021;16(1):68-79. doi: 10.51362/neonatology.today/20211616879. 

55. van Stralen D, Mercer TA. High-Reliability Organizing (HRO) in the COVID-19 Liminal Zone: Characteristics of Workers and Local Leaders. Neonatology Today. 2021;16(4):90-101. doi: 10.51362/neonatology.today/2021416490101. 

56. Starbuck WH. Karl E. Weick and the dawning awareness of organized cognition. Management Decision. 2015;53(6):1287-99. doi: 10.1108/md-04-2014-0183. 

57. Robins RW, Gosling SD, Craik KH. Macroscope: Psychological Science at the Crossroads. American Scientist. 1998;86(4):310-3. 

58. Kunda Z. The case for motivated reasoning. Psychological bulletin. 1990;108(3):480. 

59. Kraft PW, Lodge M, Taber CS. Why people “don’t trust the evidence” motivated reasoning and scientific beliefs. The ANNALS of the American Academy of Political and Social Science. 2015;658(1):121-33. 

60. Cotter RG, Lodge M, Vidigal R. The boundary conditions of motivated reasoning. The Oxford Handbook of Electoral Persuasion: Oxford University Press, USA; 2020. p. 66. 

61. Epley N, Gilovich T. The Mechanics of Motivated Reasoning. Journal of Economic Perspectives. 2016;30(3):133-40. doi: 10.1257/jep.30.3.133. 

62. Bénabou R, Tirole J. Mindful Economics: The Production, Consumption, and Value of Beliefs. Journal of Economic Perspectives. 2016;30(3):141-64. doi: 10.1257/jep.30.3.141. 

63. Druckman JN, Leeper TJ, Slothus R. Motivated Responses to Political Communications: Framing, Party Cues, and Science Information In: Lavine H, Taber CS, editors. The Feeling, Thinking Citizen: Essays in Honor of Milton Lodge. Routledge Studies in Political Psychology. 5. N.Y., NY: Routledge; 2018. p. 124-50. 

64. Boyd J. The Strategic Game of ? and ? In: Hammond GT, editor. A discourse on winning and losing. Maxwell AFB, Alabama: Air University Press; 2018. p. 255-314. 

Disclosures: The authors have no relevant disclosures