Alan Shirley

GP, GP trainer, TPD Sheffield

              

 Making Decisions Better-        

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 of variablesSmall number of variables

Allocate value to those variablesAllocate value to those variables Time frameTime frame DECISIONDECISION==++ ++

Satisficing

Bounded rationalitySatisficing

- please find a piece of paper and a pen

- a list of words followslook at them once, do not re-read them- when you have read the list close your eyes

FlangeRoutemasterLaggardSausagesAutomatonApproachAntichristResearchSlipperHaggleFridgeLocomotiveBracketConfusedTelesalesProfessorStool pigeonHaleBanquetIrrelevance

Write down as many words as you can remember

FlangeRoutemasterLaggardSausages

AutomatonApproachAntichristResearch

SlipperHaggleFridgeLocomotive

BracketConfusedTelesalesProfessor

Stool pigeonHaleBanquetIrrelevance

AA

BB

CC

DD

EE

How many wordsthat you remembered are in each group?

How many wordsthat you remembered are in each group?

Dual-process theoryHuman judgementHeuristics and biases

Who knows the story of Noah in the Bible?

• Imagine you are working as a doctor in a remote village. Imagine you are working as a doctor in a remote village. It’s the weekend. There are no other health care It’s the weekend. There are no other health care professionals around. But you do have a new piece of professionals around. But you do have a new piece of technology called THE MARVELTRONtechnology called THE MARVELTRON

• The MARVELTRON will save the life of any patient you The MARVELTRON will save the life of any patient you are treating.are treating.

• But you have to answer correctly the question the But you have to answer correctly the question the MARVELTRON asks of the attending doctor before it MARVELTRON asks of the attending doctor before it works its magic.works its magic.

• A young child is brought to you. She is seriously ill and will A young child is brought to you. She is seriously ill and will die imminently.die imminently.

• You switch on the MARVELTRON and await the question.You switch on the MARVELTRON and await the question.• You must write down your answer immediately the You must write down your answer immediately the

question is asked, or the child will die.question is asked, or the child will die.• You will be blamed for the patient’s death only if you do You will be blamed for the patient’s death only if you do

not write down an answer. No blame will be attached to not write down an answer. No blame will be attached to you if you get the answer wrong. you if you get the answer wrong.

• ARE YOU READY? ARE YOU READY? • Have you got paper and something to write with?Have you got paper and something to write with?

• According to the Bible, how many According to the Bible, how many giraffes did Noah take into the Ark?giraffes did Noah take into the Ark?

• Answer quicklyAnswer quickly• Write it downWrite it down• The child is dying.The child is dying.

How many giraffes?How many giraffes?

• 00• 11• 22• 33• 44• 55• 66• 77• More than 7More than 7

The correct answerThe correct answer

• Of every Of every clean beast clean beast thou shalt take to thee by thou shalt take to thee by sevenssevens, ,

the the male and his femalemale and his female: : and of beasts that are not clean by twoand of beasts that are not clean by two, , the male and his female. Of fowls also of the air by sevens, the 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 male and the female; to keep seed alive upon the face of all the earth.earth.

Genesis. Ch 7Genesis. Ch 7

Whatsoever parteth the hoof, and is cloven-footed, and Whatsoever parteth the hoof, and is cloven-footed, and cheweth the cud, among the beasts, that shall ye eat.cheweth the cud, among the beasts, that shall ye eat.

Leviticus Ch 11Leviticus Ch 11

• Where did you get the information from to Where did you get the information from to make the decision about Noah and the make the decision about Noah and the giraffes?giraffes?

• If you had had time, what would you have If you had had time, what would you have done to make sure you had the right answer?done to make sure you had the right answer?

Hard wiringAmbient conditions/ContextTask characteristicsAge and ExperienceAffective stateGenderPersonality

EducationEducationTrainingTrainingCritical thinkingCritical thinkingLogical competenceLogical competenceRationalityRationalityFeedbackFeedbackIntellectual abilityIntellectual ability

Pattern Recognition

Repetition

Executiveoverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

Type11

Processes

Type22

Processes

T

Croskerry P. Context is everything or how could I have been that stupid. Healthcare Quarterly; Vol 12, Special issue 2009Croskerry P. Context is everything or how could I have been that stupid. Healthcare Quarterly; Vol 12, Special issue 2009

DiagnosisDiagnosis RxRx

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

It is most likely that Steve is a ……

1.1. FarmerFarmer

2.2. PharmacistPharmacist

3.3. Disc jockeyDisc jockey

4.4. LibrarianLibrarian

5.5. Member of ParliamentMember of Parliament

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

Vanderbilt UniversityBasic 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?

AnswersA. 35B. 2C. 46½ hours____________________________________D. The ball costs 5p and the bat £1.05E. 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

Foreground Influences

Clinical episodeClinical episode Clinical decisionClinical decision Clinical outcomeClinical outcome

Defences

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

• 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

• 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:-

– 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