Overview of Medical Decision Making

1. Overview of Medical Decision Making HINF 371 - Medical Methodologies Session 2

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

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

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

5. Decision Making Steps Analysis Evidence Judgments Judgments Preferences Policy

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

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

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

9. Avoidance of pitfalls • Decisions must be based on outcomes that are important to patients • 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

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

11. How is this evidence prepared

12. Discussion – How can we support this process?