Intuition, rapid response teams and thinking out loud

Intuition, Rapid Response Teams
and Mentoring
Thomas A. Iannucci, M.D., FACOG
Department of Maternal-Fetal Medicine
Advocate Lutheran General Hospital
Making Decisions
• Decision-making is commonly described as a
multistage process
– Define a problem
– Generate alternatives
– Evaluate options (possible formal analytical
– Choice
– Implement decision
Making Decisions
• How does intuition work when making decisions?
– Assess situation
come to a solution
– No comparison of alternatives
– Referring to Critical, Complex decisions, not simple
• What are we using in these cases?:
– Sixth sense
– Intuition
– Gut
Making Decisions
• What is intuition?
• Is it just there?
• Can we improve our intuition?
– To improve it we need to better understand how
intuition works
• Can we actually harness and enhance our
intuition to become better decision makers?
• Can we share our intuition?
Making Decisions
• Gary Klein, PhD-psychologist researching
• Asked fire commanders about making life and
death decisions
• When questioning how they made difficult
decisions, he concluded they frequently
resorted to intuition.
Intuition in Decisions
• He asked fire commanders about their most
challenging situations
– One commander stated that E.S.P. played a role in
a particular situation
– He firmly believed that he had experienced extra
sensory perception…
Intuition in Decisions
• Situation:
– The commander’s crew had arrived at a fire that
appeared to be a simple contained, kitchen fire.
– The fire however was not responding to the direct
water spray from the living room
– He also noted that the fire was much hotter than
– His “sixth sense” then kicked in
– He pulled his crew completely out of the house
Intuition in Decisions
• Soon after they left the
house the living room floor
Intuition in Decisions
• Klein then asked him why he made the
decision to pull the crew out
– He was surprised that the water had no effect on
a seemingly small fire
– He was puzzled at how hot the fire was
– He thought it seemed odd at how quiet the fire
was from the living room
Intuition in Decisions
• His explanation was summarized by
– He pattern he saw did not fit
– The situation violated his expectations
– Frankly, he wasn’t sure what was going on
Intuition in Decisions
• Overall, our experiences provide us with an
expected set of patterns.
– Intuition is fundamentally a pattern recognition
• We use our expectations of these patterns to
match with a given situation
• At times we cannot always verbalize what is
wrong when these patterns don’t match, but we
innately know that the pattern doesn’t match.
Intuition in Decisions
• In follow-up studies Klein studied other
professions including:
– Military commanders
– Pilots
– Nurses
• He found that intuition played a powerful role
in how experts in all fields “sized up" a
situation and made decisions.
Intuition in Decisions
• Intuition is fundamentally a pattern
recognition process
– The patterns are formed from past experience
– The process occurs very quickly
– Unlike other decision-making processes we don’t
think through a series of alternatives
Intuition in Decisions
• Intuition gradually develops as someone gains
a deep expertise in a specific field
• More situations lead to an increased ability to
recognize and match patterns
• The thought is that while we are not always
aware of it our mind is always searching for
patterns for all situations that we encounter
• We use pattern recognition to spot problems
and quickly guide us to solutions
Intuition and RRT’s
• Klein interviewed many nurses and physicians
in his study of intuition
– He realized that these professionals frequently use
intuition to make decisions
– The patterns we look for are those assembled
• Vital signs, laboratory data, symptoms, physical
findings, and in obstetrics electronic fetal monitoring
Intuition and RRT’s
• There was a clear distinction between novices
and experts and their ability to match patterns
• He often found that with experience nurses
and physicians often sensed something wasn’t
right before the data became clear
• How can we use this to improve patient care?
Intuition and RRTs
• Studies in England in the late ‘90s showed that
in the hours before a patient had a cardiac
arrest or other serious problems there were
subtle signs of deterioration
• Efforts were made to find ways of detecting
these changes more proactively
• Their interviews of many nurses after critical
events occurred
Intuition and RRTs
• Discussions with nurses often lead to the
realization that these nurses knew something
wasn’t right and they had “a feeling” that
things were turning for the worse
• This led to the development of rapid response
Intuition and RRTs
• Rapid response teams are mean to lead to an
evaluation of the patient prior to them
reaching a critical situation
• This is distinctly different than code teams
which are called after a critical situation is
– This distinction is critical!!
Intuition and RRTs
• The 100,000 Lives Campaign is a nationwide
initiative launched by the Institute for
Healthcare Improvement (IHI) to significantly
reduce morbidity and mortality in American
health care.
• Deploy Rapid Response Teams…at the first
sign of patient decline
Intuition and RRTs
• Based on research showing that patients often
exhibit signs and symptoms of increasing
instability for several hours prior to a cardiac
arrest — changes in breathing, heart rate, or
mental status, for example — the idea is to
rescue patients early in their decline before a
crisis occurs.
Intuition and RRTs
• The Rapid Response Team
intervenes upstream from
a potential code situation,
relying on bedside nurses
who are highly sensitive
to signs that a patient’s
condition is deteriorating,
and empowered to call
others into action.
• Intuition is fundamentally
a pattern recognition
– The patterns are formed
from past experience
– The process occurs very
– Unlike other decisionmaking processes we don’t
think through a series of
Intuition and RRTs
• Technical skills:
• Adult advanced cardiac life support certification
• Pediatric advanced life support certification
• Critical care experience
• Critical thinking
• Assessment and diagnostic abilities
• Ability to communicate concisely
• Ability to recognize when they are unable to meet
the patient's needs
Intuition and RRTs
– The attitude of the team members toward the
bedside staff, patient and families has a direct link
to the overall success of the rapid response team
– It is imperative for the responders to keep in mind
that "all rapid response team calls are warranted."
– If the bedside staff member does not feel
respected and appreciated, or is intimidated by
the responding staff, he/she may be reluctant to
call the rapid response team in the future.
Rapid Response Team. Third Edition/May 2009
RRTs- other benefits
• Experts and novices at bedside
• People tend take the opportunity to
share their intuition with others
• Through discussion of the case,
experts can help develop the
intuition of novices
RRTs- other benefits
• Bedside patient discussions with
the entire team present allows a
level of teaching that cannot be
accomplished in a classroom
Passing on of Wisdom
• The definition of apprenticeship
• Socrates-the Socratic method
– a form of inquiry and debate between individuals
with opposing viewpoints based on asking and
answering questions to stimulate critical thinking
and to illuminate ideas
– It is a dialectical method, often involving an
oppositional discussion in which the defense of
one point of view is pitted against the defense of
Passing on of Wisdom
Thinking out loud
–A key practice to use at bedside
• Literally, talking through a thought
• Not to be confused with second guessing
• Explanations must be reassuring
Passing on of Wisdom
Thinking out loud
–I’m doing this for the patient because…
–I’m looking at this data because…
–I’m concerned about this patient
–Why does this change in vital signs
concern me…
Passing on of Wisdom
• Thinking out loud
–Using this process experts can share
how they develop intuition
–Thought processes going on in the
mind of an expert
–An optimal form of mentoring
Passing on of Wisdom
• Mentoring
– Mentoring is ultimately how intuition is
optimally shared and developed
– It requires
• Astute observation by the mentor and the
• Astute listening by the inexperienced
• Empathy by the mentor
• Excellent communication skills by the mentor
Passing on of Wisdom
• Pitfalls of using intuition
– Misuse of analogy
• He picked the wrong analogy
– Can make the wrong match to the situation
• Picked the wrong pattern
– Overly complex situation
• Complexity of the situation can obscure pattern recognition
• “Too much noise” Too many patterns or can’t see the most
important pattern
• Outdated mental models- New data causes out dating of
information. Keeping up with new information
Passing on of Wisdom
Pitfalls of Mentoring
• People need to understand your rationale and
your intent in order to apply knowledge
• Communicate your intuition, get feedback
• Ensure alignment– Make sure what you want them to do and what
they think you want them to do are the same
Passing on of Wisdom
• Five steps:
Here is what I think is going on
Here is what I think we should do
This is why/my rationale
Here is what we need to watch for
Tell me what you think
• Tell what you understand of what I said
• Are there any issues with my thinking?
• There is a link between intuitive thinking, the
theory behind rapid response teams and how
we can mentor less experienced members of
our team
• Optimal thought processes and teaching are
best done using a combination of intuition
and analytical thinking
• Roberto, MA. The Art of Critical Decision Making. Chantilly,
VA: The Teaching Company, 2009.
• Client, G. Sources of power: How People Make Decisions.
Cambridge MA: MIT Press, 1999.
• Gladwell, M. Blink: The Power of Thinking Without Thinking.
• Healthcare Protocol: Rapid Response Team. Institute for
Healthcare Clinical Improvement. Third ed., May 2009
• Institute for Healthcare Improvement. Rapid response
information. Online