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Making Decisions Better Alan Shirley Programme Director Sheffield GP Specialty Training Programme @ralanshirley

Human decision making How do human beings make decisions? 40+ years psychological research Un(der) used in medicine

How do you make decisions? What is your model of clinical decision making?

Bounded rationality

Bounded rationality Satisficing

Dual-process theory Human judgement Heuristics and biases Amos Tervsky

2 Type 1 T Type Diagnosis Calibration Hard wiring Ambient conditions/Context Task characteristics Age and Experience Affective state Personality Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override T Dysrationalia override Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED Education Training Critical thinking Logical competence Rationality Feedback Intellectual ability Croskerry P. Context is everything or how could I have been that stupid. Healthcare Quarterly; Vol 12, Special issue 2009

Type 1 Thinking Intuition Gut feeling “I just know” Sixth sense Spidey- sense Expert skilled pattern recognition

Type 1 Thinking Fast/Easy/Effortless Low cognitive load Skilled, reflex actions More prone to bias/emotion Pattern recognition Rules of thumb/Heuristics Error more common Unconscious/Unaware of thinking “Professional artistry” [Schon]

Type 2 Thinking Slow/hard/effortful High cognitive load Deliberate actions Less prone to bias/emotion Rules/guidelines/algorithms Reflection/return to first principles Error less common Conscious/Aware of thinking “Technical, rational professionalism”

All together, big breath in……… What is the answer to this sum?

2 + 2 =

All together, big breath in……… What is the answer to this sum?

75 x 56 =

All together, big breath in……… Is the answer to this sum right or wrong?

75 x 56 = 678

Say OUT LOUD what you see on the next slide

Diabetes - Risk Management & New Drugs 12/09/2018 Vanderbilt University Basic Course in Medical Decision Making National Prescribing Centre 24

Diabetes - Risk Management & New Drugs 12/09/2018 National Prescribing Centre 25

Diabetes - Risk Management & New Drugs 12/09/2018 National Prescribing Centre 26

Diabetes - Risk Management & New Drugs 12/09/2018 National Prescribing Centre 28

Diabetes - Risk Management & New Drugs 12/09/2018 National Prescribing Centre 29

Effect of Affect

Situational/Affective Affective state of doctor Health of doctor HALT Workload/Timing Knowledge Clinical Familiarity

Decision making processes Bounded rationality Dual Process Cognitive Biases Limitations of processing/cognitive overload Effect of Affect Core concepts *

Teamwork Communication Defences Background Influences Clinical episode Clinical decision Clinical outcome Defences Communication Foreground Influences

Reason’s “Swiss cheese” model of accident causation Some holes due to active failures Hazards Other holes due to latent conditions Losses Successive layers of defences, barriers and safeguards System defences *

How can we do better? Meta-cognition Self awareness Cognitive forcing functions Decision aids when appropriate Safe working environments

“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

Features of Metacognition Awareness of the learning process and the cognitive demands of a particular situation Recognition of the limitations of memory Ability to appreciate the broader perspective Capacity for self critique Ability to select a particular strategy for improving the decision making, particularly when things don’t fit Simon

“Think as well as blink”? Background factors Self awareness: our own Common biases Attitude to risk Under/over confidence System 1/system 2 preference More risky situations/patients/presentations

A bat and a ball cost £1. 10 in total. The bat costs £1 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 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 The ball costs £1.05 and the bat 5p 5 minutes 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)

“Think as well as blink”? Foreground factors Right system right time Know when to slow down AND when to trust your gut Use a systematic approach to common problems – where validated tools Acknowledge emotional/affective factors What doesn’t fit? What else could it be

Who is this?

Stanislav Petrov 26th Sept 1983 Lt colonel evaluating incoming data Satellite signal 5 missiles launched Alarms going “funny feeling in my gut” Analysis: only 5 nil from ground radar

“Think as well as blink”? Cognitive forcing functions ATM money/card Restricted rule out – worst case Restricted rule in – likely diagnosis Reframe when recording Decrease reliance on memory Checklists

3 S “checklist” Summarising: reframing the story checking for bias Signposting: think aloud Safetynetting: what else might happen? what if I am wrong? All involve the patient

Dunning-Kruger “the fool doth think he is wise, but the wise man knows himself to be a fool” Novices overestimate relative ability – failure of metacognition Experts underestimate relative ability – underestimate difficulty for others

Top tips Make the implicit: explicit Process not outcome Timeliness Be specific Integrate consultation skills Effect of affect