Nada Kholeif
“You are here to know how to take the best possible decision in the right time not only to memorize some information”
A few weeks ago, I attended the skill lab sessions in college. They are part of the requirements of the surgery round for 6th year medical students in which certain skills like suturing, putting a catheter, nasogastric tube and steps of resuscitation are practiced.
At the end of the sessions, a doctor told us the above sentence. This actually hit hard for me. As it made me realize that the real reason behind gathering all this information and studying for all those years is to be able to have the tools that enable correct decision-making.
How our brains work
In 1978, Herbert Simon was awarded the Nobel Prize in economic sciences for describing the concept of ‘bounded rationality’. The concept explains that there is too much relevant information for the decision maker to process or know. Therefore, human beings abbreviate or cut short the large volumes of information.
This may be startling as we assume that our clinicians base their decisions on large amount of scientific data, years of experience and training.
For example, a patient may present with headache. In order for the physician to diagnose, he/she must know the anatomy of the brain, pathophysiology, differential diagnosis, certain case patterns, and clinical examination. In order to make a good decision, the physician must go through these large volumes of information and truncate what is not needed.
In 1986, Richard E. Petty and John Cacioppo proposed the dual process theory. Their theory states that human process information in two different routes or systems. System 1 is automatic, fast, effortless, and intuitive. It is developed through repetition and experience. System 2 takes more effort, as it requires careful and deliberate processing and rational analysis of information.
Neither system is better than the other. Each is needed at certain times. For example, system 1 is used in emergency life threatening decisions and system 2 is needed when we are not sure about the diagnosis or cannot process by system 1.
Being aware of these systems and intertwining them in different situations can improve clinical decision-making process.
Decision-Making Approaches
Several decision-making approaches have been developed to incorporate knowledge with experience. These include:
Patterns. In medical school, most, if not all, of us are trained to recognize patterns. For example, a 65 years old male who is a chronic heavy smoker with a chest complaint like cough makes us probably think of bronchogenic carcinoma.
Scientific method. Each patient is considered a research project in which we try to answer a problem by developing a hypothesis then analyzing and researching data to corroborate or reject the hypothesis.
Differential diagnosis. In medical school we learn by heart many lists of differential diagnosis to help us sort out our probabilities. Some doctors like to start with the commonest on the list. Others like to rule out the most dangerous first.
Tests. Tests are very useful in helping us reach our clinical diagnosis. We must know the first tests to be used and the gold standard for each diagnosis and also remember that there are normal variations in patients and ranges in each test.
The Four Pitfalls in Decision-Making
Satisfaction of the search is the tendency to make a decision and rule out alternatives.
Diagnosis momentum is the tendency to ignore new findings or date that might deviate the already headed decision.
Commission bias is the tendency to do something or any intervention rather than follow up and watchful waiting.
Intuitive leap is the tendency to make a diagnosis without enough data or supported evidence.
A Shared Decision
Clinical decisions are not only made by the expert physician but also made by the patient. The decision is a shared one. The doctor explains the diagnostic procedures, disease nature, progression, prognosis, and treatment options. The patients also discuss their previous illnesses, socioeconomic state, habits, values and preferences. Together the most suitable decisions can be made.
Making the right decision is never easy as there are many variables and large amount of information to process. Optimizing our lives for fewest regrets takes conscious effort and skill.
As physicians, this can be even more challenging as we directly deal with people’s lives and are faced with life and death decisions. We try our best to develop our skills, to become aware of our biases and to combine different approaches of clinical decision-making process.
At the end, everything in life is a choice. Make sure you make a good one.
References
Groopman J. How Doctors Think. Boston: Houghton Mifflin; 2007.
O'Connor AM, Llewellyn-Thomas HA, Flood AB. Modifying unwarranted variations in health care: shared decision making using patient decision aids. Health Affairs (Millwood). 2004;Suppl Web Exclusive:VAR63–VAR72.
Borrell-Carrio F, Epstein RM. Preventing errors in clinical practice: a call for self-awareness. Ann Fam Med. 2004;2:310–316.
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84:1022–1028. [PubMed] [Google Scholar]
Croskerry P. Context is everything or how could I have been that stupid? Healthc Q. 2009;12:e171–176. [PubMed] [Google Scholar]
Simon HA. Rational decision-making in business organizations. Nobel Memorial Lecture. 8th December 1978. Available at http://nobelprize.org/nobel_prizes/economics/laureates/1978/simon-lecture.pdf (last accessed 20 July 2012)
Petty, Richard; Cacioppo, John (1986). The Elaboration Likelihood Model of Persuasion. Advances in Experimental Social Psychology. 19. pp. 123–181. doi:10.1016/s0065-2601(08)60214-2. ISBN 9780120152193.
Comentários