Making Decisions Better
-
Alan Shirley
GP, GP trainer, TPD Sheffield
a.shirley@sheffield.ac.uk
Opening the black box
• Tim Norfolk
• Neal Maskrey
• Pat Croskerry
What I want to talk about
 How human beings think and make decisions
 How clinical decisions are made
 How clinical decision-making may be improved
 How to help learners become better decision
makers
Your need to replace your car.
Be realistic. What would you
consider when making your selection?
Humans usually make decisions by……
Small number + Allocate value to+
Time frame = DECISION
of variables
those variables
Satisficing
Bounded rationality
Satisficing
- please find a piece of paper and a pen
- a list of words follows
look at them once, do not re-read them
- when you have read the list close your
eyes
Flange
Routemaster
Laggard
Sausages
Automaton
Approach
Antichrist
Research
Slipper
Haggle
Fridge
Locomotive
Bracket
Confused
Telesales
Professor
Stool pigeon
Hale
Banquet
Irrelevance
Write down as many words as you can
remember
A
B
Flange
Routemaster
Laggard
Sausages
Automaton
Approach
Antichrist
Research
C
Slipper
Haggle
Fridge
Locomotive
D
Bracket
Confused
Telesales
Professor
E
Stool pigeon
Hale
Banquet
Irrelevance
How many words
that you remembered
are in each group?
Dual-process theory
Human judgement
Heuristics and biases
Who knows the story of Noah in the
Bible?
• Imagine you are working as a doctor in a remote village.
It’s the weekend. There are no other health care
professionals around. But you do have a new piece of
technology called THE MARVELTRON
• The MARVELTRON will save the life of any patient you
are treating.
• But you have to answer correctly the question the
MARVELTRON asks of the attending doctor before it
works its magic.
• A young child is brought to you. She is seriously ill and will
die imminently.
• You switch on the MARVELTRON and await the question.
• You must write down your answer immediately the
question is asked, or the child will die.
• You will be blamed for the patient’s death only if you do
not write down an answer. No blame will be attached to
you if you get the answer wrong.
• ARE YOU READY?
• Have you got paper and something to write with?
• According to the Bible, how many
giraffes did Noah take into the Ark?
• Answer quickly
• Write it down
• The child is dying.
How many giraffes?
•
•
•
•
•
•
•
•
•
0
1
2
3
4
5
6
7
More than 7
The correct answer
sevens
• Of every clean beast thou shalt take to thee by
,
the male and his female: and of beasts that are not clean by two,
the male and his female. Of fowls also of the air by sevens, the
male and the female; to keep seed alive upon the face of all the
earth.
Genesis. Ch 7
Whatsoever parteth the hoof, and is cloven-footed, and
cheweth the cud, among the beasts, that shall ye eat.
Leviticus Ch 11
• Where did you get the information from to
make the decision about Noah and the
giraffes?
• If you had had time, what would you have
done to make sure you had the right answer?
Hard wiring
Ambient
conditions/Context
Task characteristics
Age and Experience
Affective state
Gender
Personality
RECOGNIZED
Type
1
Process
es
Patient
Presentation
Pattern
Processor
Pattern
Recognition
Executive
override
T
Dysrationalia
override
Calibration
Diagnosis
Repetition
NOT
RECOGNIZED
Education
Training
Critical thinking
Logical competence
Rationality
Feedback
Intellectual ability
Type
2
Process
es
Croskerry P. Context is everything or how could I have been
that stupid. Healthcare Quarterly; Vol 12, Special issue 2009
Diagnosis
Rx
Say OUT LOUD what you see on the next slide
System 1 Processing
• Pattern recognition
• Based on experience
• Illness Scripts
• Cases
• Short cuts
• Mental maps
• Heuristics
• Rules of thumb
Some biases
• Framing effect who/how story previous
info “triage cueing”
• Anchoring bias – early salient feature
• Confirmation bias – search for info
supporting hypothesis –ignoring info
refuting
• Search satisfycing – found one thing,
ignore others
• Availability bias – easily recalled
experience dominates evidence
• Representativeness – several features
typical but other explanation more likely
Some more biases
• Bandwagon effect – we do it this way
here
• Sutton’s slip – going for the obvious
• Gambler’s fallacy – I’ve seen 3 recently;
this can’t be a fourth
• Vertical line failure – routine repetitive
tasks leading to thinking in silo
• Visceral bias – emotional response/
countertransference
• Overconfidence
• Blind spot bias – other people are
susceptible to these biases but I am not
Contextual/Affective
•
•
•
•
•
•
Affective state of doctor
Health of doctor
Tiredness/sleep deficit
Workload/Timing
Knowledge
Clinical Familiarity
Steve is very shy and withdrawn, invariably helpful,
but with little interest in people. He has a need for
order and structure and a passion for detail
It is most likely that Steve is a ……
1.
2.
3.
4.
5.
Farmer
Pharmacist
Disc jockey
Librarian
Member of Parliament
Vanderbilt University
Basic Course in Medical Decision Making
Six Quick Questions
Please find a piece of paper and write down your
answers to each of these six questions
You have about 10 seconds for each response
On a fire engine, there are 2 drivers up front, one
at the rear and four additional fire-fighters. What
is the total personnel required for 5 standard
trucks?
How many turtle doves did my true love send me
on the 2nd day of Christmas?
In 2008, the average time required to complete a
root cause analysis was 15½ hours, how much
time should be allowed for the three that are
expected next month?
A bat and a ball cost £1.10 in total. The bat costs £1.00
more than the ball.
How much does the ball cost?
If it takes 5 machines 5 minutes to make 5
widgets, how long would it take 100 machines to
make 100 widgets?
In a lake, there is a patch of lily pads. Every day,
the patch doubles in size. If it takes 48 days for
the patch to cover the entire lake, how long
would it take for the patch to cover half the lake?
Answers
A. 35
B. 2
C. 46½ hours
____________________________________
D. The ball costs 5p and the bat £1.05
E. 5 minutes
F. 47 days
Cognitive Reflective Test
• The test distinguishes intuitive (system 1) from analytical (system 2)
processing….
• …….the ability to resist first response that comes to mind
• Of 3428 people tested only 17% got all 3 correct
• 33% answered all three incorrectly
Frederick 2002 (MIT)
Opening the Black Box
Evidence Based Medicine
• .. is the conscientious, explicit and judicious use of
current best evidence in making decisions about the care
of individual patients. The practice of evidence-based
medicine means integrating individual clinical expertise
with the best available external clinical evidence from
systematic research. …Increased expertise is reflected
in many ways, but especially …in the more thoughtful
identification and compassionate use of individual
patients' predicaments, rights, and preferences in
making clinical decisions about their care.
Sackett D,1996
Background
Influences
Clinical episode
Clinical decision
Clinical outcome
Defences
Foreground
Influences
CSA/Trainees in difficulty
It’s all about……
• Communication Skills
• Culture
• Clinical decision making
Better is possible.
It does not take genius, it
takes diligence, it takes a
clarity of purpose, it takes
ingenuity, it takes a
willingness to try.
“Think as well as blink”?
Metacognition
“The process by which we reflect upon, and
have the option of regulating, what we are
thinking”
• “thinking about thinking”
• remembering to stand back + observe our
own thinking
The Cognitive Imperative: Thinking about How We Think
Croskerry 2000 Academic Emergency Medicine
“Think as well as blink”?
• Background factors
•
•
•
•
•
Self awareness: our own
Common biases
Attitude to risk
System 1/system 2 preference
More risky situations/patients/presentations
“Think as well as blink”?
• Foreground factors
• Consider the unintended consequences of
pursuing this diagnosis
• Use a systematic approach to common
problems
• Acknowledge how the patient makes you feel
• Ask yourself: “What doesn’t fit? What can’t we
explain?”
• Know when to Slow Down
“Think as well as blink”?
• Process factors: Cognitive forcing functions
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•
•
•
Diagnostic “timeout”
Consider the opposite
Consider the worst case
Use “prospective hindsight”: look into the future
and see what would happen if our diagnosis
was wrong.
• Checklists
2 S “checklist”
• Summarising
• In order to summarise to the patient I have to work out
what the story means
• Am I in the right system? what else could it be? what
biases may be affecting me? what assumptions have I
made?
• Safetynetting
• In order to safety net specifically I need to have
considered:
• What else might happen? What if I am wrong?
“Prospective Hindsight”: the final "regret filter"
• Both involve the patient
What to teach 121
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The “content”
Knowledge + language = discourse
Debriefing “open the decision making box”
CbDs
SEAs
Videos
Joint surgeries
Trigger videos eg Wessex CSA
Encouraging: self awareness –decision making
style/biases attitude to risk/own high risk situations
• Other people’s suboptimal decisions are due to:-
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–
–
–
–
Poor information
Lack of intelligence
Lack of experience
Personality flaws of individuals
Questionable motives
Our own suboptimal decisions are due to………..
Unforeseeable change in external factors