Overview of Medical Decision Making HINF Medical Methodologies Session 2

Session Objectives To understand the stages of rational decision making in medicine To understand the stages of rational decision making in medicine To understand the information needs at each stage To understand the information needs at each stage

Reading Mar CD, Doust J, Glasziou (2006) Chapter 1: Principles of clinical problem solving, in Clinical Thinking: Evidence, Communication and Decision-Making, Blackwell Publishing and BMJ Books, USA Mar CD, Doust J, Glasziou (2006) Chapter 1: Principles of clinical problem solving, in Clinical Thinking: Evidence, Communication and Decision-Making, Blackwell Publishing and BMJ Books, USA Eddy D (1990) Anatomy of a Decision, JAMA, No.263, pp Eddy D (1990) Anatomy of a Decision, JAMA, No.263, pp Chapman G B and Sonnenberg F A (2000) Chapter 1: Introduction, in Chapman G B and Sonnenberg F A (eds) Decision Making In Health Care: Theory, Psychology and Applications, Cambridge University Press, USA, pages:11-19 Chapman G B and Sonnenberg F A (2000) Chapter 1: Introduction, in Chapman G B and Sonnenberg F A (eds) Decision Making In Health Care: Theory, Psychology and Applications, Cambridge University Press, USA, pages:11-19

Decision Making Process Experience the Situation in a changing Context Define problem and Reframe it Is situation typical? Yes ExpectanciesRelevant Clues Plausible Goals and Objectives Typical Actions Anomaly Clarify/Reframe No Diagnose More data Decide Will it work? Implement Modify Yes, but No Next Episode Experience the Situation in a changing Context Decision Making

Decision Making Steps Sorting out the problem PProblem Define the problem. How does the problem affect health? R Reframe the Problem From multiple perspectives: think everyone’s, now and in the future OObjectives What is the best outcome we could achieve? Provider’s objectives, Patient’s objectives ActionAAlternatives List alternatives (treat, wait and see, or test) CConsequences Imagine outcome of each alternative TTrade-offs Review benefits and harms of each alternative Integration I V Values What are the patient values and preferences? What are the practitioner’s values and preferences? EExploration 1. Benefits of a practice must be compared with the harms 2. Health outcomes must be compared to costs 3. Compare benefits and costs of each alternative Analysis Judgments Evidence Judgments Preferences Policy

But can we do all in minutes? Novice Novice Rigid adherence to taught rules or plans Rigid adherence to taught rules or plans Little situational perception Little situational perception No discretionary judgement No discretionary judgement Competent Competent Is able to cope with “crowdness” and pressure Is able to cope with “crowdness” and pressure Sees actions partly in terms of long-term goals or a wider conceptual framework Sees actions partly in terms of long-term goals or a wider conceptual framework Follows standardized and routinized procedures Follows standardized and routinized procedures Expert Expert No longer relies explicitly on rules, guidelines and maxims No longer relies explicitly on rules, guidelines and maxims Has an intuitive grasp of situations based on deep, tacit understanding Has an intuitive grasp of situations based on deep, tacit understanding Uses analytic approaches only in novel situations or when problems occur Uses analytic approaches only in novel situations or when problems occur

Model of decision making for experts Match each situation with a prototype Match each situation with a prototype Use their experience to create prototypes Use their experience to create prototypes

What can go wrong? Misperception of evidence Misperception of evidence Important outcomes might be ignored Important outcomes might be ignored Extraneous outcomes might be included Extraneous outcomes might be included Evidence might be incomplete Evidence might be incomplete Existing evidence might be overlooked Existing evidence might be overlooked Evidence might be misinterpreted Evidence might be misinterpreted Incorrect reasoning Incorrect reasoning Personal experiences might be given undue weight Personal experiences might be given undue weight Wishful thinking takes precedence Wishful thinking takes precedence Misperception of the patients values on the outcomes Misperception of the patients values on the outcomes Patient misunderstand the outcomes Patient misunderstand the outcomes Measure of the effect could be misleading Measure of the effect could be misleading Presentation of outcomes might be misleading (e.g. ARR RRR) Presentation of outcomes might be misleading (e.g. ARR RRR) No attention paid to patients values No attention paid to patients values Provider project their own values and preferences to the patient Provider project their own values and preferences to the patient

Avoidance of pitfalls Decisions must be based on outcomes that are important to patients Decisions must be based on outcomes that are important to patients The effects of a practice on outcomes should be estimated accurately. The effects of a practice on outcomes should be estimated accurately. Preferences assigned to the outcomes of an intervention should reflect as accurately as possible the preferences of the people who receive the outcomes - patients Preferences assigned to the outcomes of an intervention should reflect as accurately as possible the preferences of the people who receive the outcomes - patients

Extraneous Outcomes Type of evidence (no RCTs therefore can use case results) Type of evidence (no RCTs therefore can use case results) Degree of certainty (significance) Degree of certainty (significance) Common sense Common sense Commonness of disease Commonness of disease Seriousness of the outcome Seriousness of the outcome The need to do something The need to do something Novelty and technical appeal of an intervention Novelty and technical appeal of an intervention Pressure from patients, family, press, courts, paperwork, financial interests Pressure from patients, family, press, courts, paperwork, financial interests

How is this evidence prepared

Discussion – How can we support this process? Sorting out the problem PProblem Define the problem. How does the problem affect health? R Reframe the Problem From multiple perspectives: think everyone’s, now and in the future OObjectives What is the best outcome we could achieve? Provider’s objectives, Patient’s objectives ActionAAlternatives List alternatives (treat, wait and see, or test) CConsequences Imagine outcome of each alternative TTrade-offs Review benefits and harms of each alternative Integration I V Values What are the patient values and preferences? What are the practitioner’s values and preferences? EExploration 1. Benefits of a practice must be compared with the harms 2. Health outcomes must be compared to costs 3. Compare benefits and costs of each alternative