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

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

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

5. Bounded rationality

6. Bounded rationality
Satisficing

7. Dual-process theory Human judgement Heuristics and biases Amos Tervsky

8. 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

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

10. 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]

11. 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”

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

13. 2 + 2 =

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

15. 75 x 56 =

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

17. 75 x 56 = 678

18. Say OUT LOUD what you see on the next slide

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

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

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

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

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

30. Effect of Affect

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

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

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

34. 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 *

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

37. “Think as well as blink”?

38. 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 Academic Emergency Medicine

39. 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

40. “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

41. 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?

42. If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets?

43. 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?

44. Answers
The ball costs £1.05 and the bat 5p
5 minutes
47 days

45. 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)

46. “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

47. Who is this?

48. 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

49. “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

50. 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

51. 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

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