Overview of Medical Overview of Medical Decision MakingDecision Making

HINF 371 - Medical MethodologiesHINF 371 - Medical Methodologies

Session 2Session 2

Session ObjectivesSession Objectives

To understand the stages of To understand the stages of rational decision making in rational decision making in medicinemedicine

To understand the information To understand the information needs at each stageneeds at each stage

ReadingReading

Mar CD, Doust J, Glasziou (2006) Chapter 1: Mar CD, Doust J, Glasziou (2006) Chapter 1: Principles of clinical problem solving, in Clinical Principles of clinical problem solving, in Clinical Thinking: Evidence, Communication and Decision-Thinking: Evidence, Communication and Decision-Making, Blackwell Publishing and BMJ Books, USAMaking, Blackwell Publishing and BMJ Books, USA

Eddy D (1990) Anatomy of a Decision, JAMA, No.263, Eddy D (1990) Anatomy of a Decision, JAMA, No.263, pp.441-443pp.441-443

Chapman G B and Sonnenberg F A (2000) Chapter 1: Chapman G B and Sonnenberg F A (2000) Chapter 1: Introduction, in Chapman G B and Sonnenberg F A Introduction, in Chapman G B and Sonnenberg F A (eds) Decision Making In Health Care: Theory, (eds) Decision Making In Health Care: Theory, Psychology and Applications, Cambridge University Psychology and Applications, Cambridge University Press, USA, pages:11-19Press, USA, pages:11-19

Decision Making ProcessDecision Making ProcessExperience the Situation in a changing Context

Define problem and Reframe it

Is situation typical?

Yes

Expectancies Relevant Clues

Plausible Goals and Objectives

Typical Actions

Anomaly

Clarify/Reframe

No

Diagnose

More data

Decide

Will it work?Implement

Modify

Yes, but

No

Next EpisodeExperience the Situation in a changing Context

Dec

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Decision Making StepsDecision Making Steps

Sorting Sorting out the out the problemproblem

PP ProblemProblem Define the problem. How does the problem Define the problem. How does the problem affect health?affect health?

RR Reframe the Reframe the ProblemProblem

From multiple perspectives: think everyone’s, From multiple perspectives: think everyone’s, now and in the futurenow and in the future

OO ObjectivesObjectives What is the best outcome we could achieve? What is the best outcome we could achieve? Provider’s objectives, Patient’s objectivesProvider’s objectives, Patient’s objectives

ActionAction AA AlternativesAlternatives List alternatives (treat, wait and see, or test)List alternatives (treat, wait and see, or test)

CC ConsequenceConsequencess

Imagine outcome of each alternativeImagine outcome of each alternative

TT Trade-offsTrade-offs Review benefits and harms of each alternativeReview benefits and harms of each alternative

IntegratioIntegrationn

I VI V ValuesValues What are the patient values and preferences? What are the patient values and preferences? What are the practitioner’s values and What are the practitioner’s values and preferences? preferences?

EE ExplorationExploration 1. Benefits of a practice must be compared with 1. Benefits of a practice must be compared with the harmsthe harms

2. Health outcomes must be compared to costs2. Health outcomes must be compared to costs

3. Compare benefits and costs of each 3. Compare benefits and costs of each alternativealternative

Analysis

Judgments

EvidenceJudgments

Preferences

Policy

But can we do all in But can we do all in minutes?minutes?

NoviceNovice Rigid adherence to taught rules or plansRigid adherence to taught rules or plans Little situational perceptionLittle situational perception No discretionary judgementNo discretionary judgement

CompetentCompetent Is able to cope with “crowdness” and pressureIs able to cope with “crowdness” and pressure Sees actions partly in terms of long-term goals or Sees actions partly in terms of long-term goals or

a wider conceptual frameworka wider conceptual framework Follows standardized and routinized proceduresFollows standardized and routinized procedures

ExpertExpert No longer relies explicitly on rules, guidelines and No longer relies explicitly on rules, guidelines and

maximsmaxims Has an intuitive grasp of situations based on Has an intuitive grasp of situations based on

deep, tacit understandingdeep, tacit understanding Uses analytic approaches only in novel situations Uses analytic approaches only in novel situations

or when problems occuror when problems occur

Model of decision making Model of decision making for expertsfor experts

Match each situation with a Match each situation with a prototypeprototype

Use their experience to create Use their experience to create prototypesprototypes

What can go wrong?What can go wrong?

Misperception of evidenceMisperception of evidence Important outcomes might be ignoredImportant outcomes might be ignored Extraneous outcomes might be includedExtraneous outcomes might be included Evidence might be incompleteEvidence might be incomplete Existing evidence might be overlookedExisting evidence might be overlooked Evidence might be misinterpretedEvidence might be misinterpreted Incorrect reasoningIncorrect reasoning Personal experiences might be given undue weightPersonal experiences might be given undue weight Wishful thinking takes precedenceWishful thinking takes precedence

Misperception of the patients values on the outcomesMisperception of the patients values on the outcomes Patient misunderstand the outcomesPatient misunderstand the outcomes Measure of the effect could be misleadingMeasure of the effect could be misleading Presentation of outcomes might be misleading (e.g. Presentation of outcomes might be misleading (e.g.

ARR RRR)ARR RRR) No attention paid to patients valuesNo attention paid to patients values Provider project their own values and preferences to Provider project their own values and preferences to

the patientthe patient

Avoidance of pitfallsAvoidance of pitfalls

Decisions must be based on Decisions must be based on outcomesoutcomes that are important to patientsthat are important to patients

The effects of a practice on outcomes The effects of a practice on outcomes should be estimated accurately.should be estimated accurately.

Preferences assigned to the outcomes Preferences assigned to the outcomes of an intervention should reflect as of an intervention should reflect as accurately as possible the accurately as possible the preferences of the people who receive preferences of the people who receive the outcomes - patientsthe outcomes - patients

Extraneous OutcomesExtraneous Outcomes

Type of evidence (no RCTs therefore Type of evidence (no RCTs therefore can use case results)can use case results)

Degree of certainty (significance)Degree of certainty (significance) Common sense Common sense Commonness of diseaseCommonness of disease Seriousness of the outcomeSeriousness of the outcome The need to do somethingThe need to do something Novelty and technical appeal of an Novelty and technical appeal of an

interventionintervention Pressure from patients, family, press, Pressure from patients, family, press,

courts, paperwork, financial interestscourts, paperwork, financial interests

How is this evidence How is this evidence preparedprepared

Discussion – How can we Discussion – How can we support this process?support this process?

Sorting Sorting out the out the problemproblem

PP ProblemProblem Define the problem. How does the problem Define the problem. How does the problem affect health?affect health?

RR Reframe the Reframe the ProblemProblem

From multiple perspectives: think everyone’s, From multiple perspectives: think everyone’s, now and in the futurenow and in the future

OO ObjectivesObjectives What is the best outcome we could achieve? What is the best outcome we could achieve? Provider’s objectives, Patient’s objectivesProvider’s objectives, Patient’s objectives

ActionAction AA AlternativesAlternatives List alternatives (treat, wait and see, or test)List alternatives (treat, wait and see, or test)

CC ConsequenceConsequencess

Imagine outcome of each alternativeImagine outcome of each alternative

TT Trade-offsTrade-offs Review benefits and harms of each alternativeReview benefits and harms of each alternative

IntegratioIntegrationn

I VI V ValuesValues What are the patient values and preferences? What are the patient values and preferences? What are the practitioner’s values and What are the practitioner’s values and preferences? preferences?

EE ExplorationExploration 1. Benefits of a practice must be compared with 1. Benefits of a practice must be compared with the harmsthe harms

2. Health outcomes must be compared to costs2. Health outcomes must be compared to costs

3. Compare benefits and costs of each 3. Compare benefits and costs of each alternativealternative