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Alan Shirley GP, GP trainer, TPD Sheffield Making Decisions Better -

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Presentation on theme: "Alan Shirley GP, GP trainer, TPD Sheffield Making Decisions Better -"— Presentation transcript:

1 Alan Shirley GP, GP trainer, TPD Sheffield Making Decisions Better -

2 Opening the black box Tim Norfolk Neal Maskrey Pat Croskerry

3 What I want to talk about  How human beings think and make decisions  How clinical decisions are made  How clinical decision-making may be improved  How to help learners become better decision makers

4 Your need to replace your car. Be realistic. What would you consider when making your selection?

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8 Humans usually make decisions by…… Small number of variables Allocate value to those variables Time frame DECISION =++ Satisficing

9 Bounded rationality Satisficing

10 - please find a piece of paper and a pen

11 - a list of words follows look at them once, do not re-read them - when you have read the list close your eyes

12 Flange Routemaster Laggard Sausages Automaton Approach Antichrist Research Slipper Haggle Fridge Locomotive Bracket Confused Telesales Professor Stool pigeon Hale Banquet Irrelevance

13 Write down as many words as you can remember

14 Flange Routemaster Laggard Sausages Automaton Approach Antichrist Research Slipper Haggle Fridge Locomotive Bracket Confused Telesales Professor Stool pigeon Hale Banquet Irrelevance A B C D E How many words that you remembered are in each group?

15 Dual-process theory Human judgement Heuristics and biases

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17 Who knows the story of Noah in the Bible?

18 Imagine you are working as a doctor in a remote village. It’s the weekend. There are no other health care professionals around. But you do have a new piece of technology called THE MARVELTRONImagine you are working as a doctor in a remote village. It’s the weekend. There are no other health care professionals around. But you do have a new piece of technology called THE MARVELTRON

19 The MARVELTRON will save the life of any patient you are treating.The MARVELTRON will save the life of any patient you are treating. But you have to answer correctly the question the MARVELTRON asks of the attending doctor before it works its magic.But you have to answer correctly the question the MARVELTRON asks of the attending doctor before it works its magic.

20 A young child is brought to you. She is seriously ill and will die imminently.A young child is brought to you. She is seriously ill and will die imminently. You switch on the MARVELTRON and await the question.You switch on the MARVELTRON and await the question. You must write down your answer immediately the question is asked, or the child will die.You must write down your answer immediately the question is asked, or the child will die. You will be blamed for the patient’s death only if you do not write down an answer. No blame will be attached to you if you get the answer wrong.You will be blamed for the patient’s death only if you do not write down an answer. No blame will be attached to you if you get the answer wrong. ARE YOU READY?ARE YOU READY? Have you got paper and something to write with?Have you got paper and something to write with?

21 According to the Bible, how many giraffes did Noah take into the Ark?According to the Bible, how many giraffes did Noah take into the Ark?

22 Answer quicklyAnswer quickly Write it downWrite it down The child is dying.The child is dying.

23 How many giraffes? More than 7More than 7

24 The correct answer Of every clean beast thou shalt take to thee by sevens, the male and his female: and of beasts that are not clean by two, the male and his female. Of fowls also of the air by sevens, the male and the female; to keep seed alive upon the face of all the earth.Of every clean beast thou shalt take to thee by sevens, the male and his female: and of beasts that are not clean by two, the male and his female. Of fowls also of the air by sevens, the male and the female; to keep seed alive upon the face of all the earth. Genesis. Ch 7 Whatsoever parteth the hoof, and is cloven-footed, and cheweth the cud, among the beasts, that shall ye eat. Leviticus Ch 11

25 Where did you get the information from to make the decision about Noah and the giraffes?Where did you get the information from to make the decision about Noah and the giraffes? If you had had time, what would you have done to make sure you had the right answer?If you had had time, what would you have done to make sure you had the right answer?

26 Hard wiring Ambient conditions/Context Task characteristics Age and Experience Affective state Gender Personality EducationTraining Critical thinking Logical competence RationalityFeedback Intellectual ability Pattern Recognition Repetition Executive override Dysrationalia override Calibration Diagnosis Patient Presentation Pattern Processor R ECOGNIZED NOT RECOGNIZED Type1 Process es Type2 Process es T Croskerry P. Context is everything or how could I have been that stupid. Healthcare Quarterly; Vol 12, Special issue 2009

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28 Diagnosis Rx

29 Say OUT LOUD what you see on the next slide

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32 For the next slide, say out loud what the treatment is

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35 System 1 Processing Pattern recognition Based on experience Illness Scripts Cases Short cuts Mental maps Heuristics Rules of thumb

36 Some biases Framing effect who/how story previous info “triage cueing” Anchoring bias – early salient feature Confirmation bias – search for info supporting hypothesis –ignoring info refuting Search satisfycing – found one thing, ignore others Availability bias – easily recalled experience dominates evidence Representativeness – several features typical but other explanation more likely

37 Some more biases Bandwagon effect – we do it this way here Sutton’s slip – going for the obvious Gambler’s fallacy – I’ve seen 3 recently; this can’t be a fourth Vertical line failure – routine repetitive tasks leading to thinking in silo Visceral bias – emotional response/ countertransference Overconfidence Blind spot bias – other people are susceptible to these biases but I am not

38 Contextual/Affective Affective state of doctor Health of doctor Tiredness/sleep deficit Workload/Timing Knowledge Clinical Familiarity

39 It is most likely that Steve is a …… 1.Farmer 2.Pharmacist 3.Disc jockey 4.Librarian 5.Member of Parliament Steve is very shy and withdrawn, invariably helpful, but with little interest in people. He has a need for order and structure and a passion for detail

40 Vanderbilt University Basic Course in Medical Decision Making

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45 Six Quick Questions Please find a piece of paper and write down your answers to each of these six questions You have about 10 seconds for each response

46 On a fire engine, there are 2 drivers up front, one at the rear and four additional fire-fighters. What is the total personnel required for 5 standard trucks?

47 How many turtle doves did my true love send me on the 2 nd day of Christmas?

48 In 2008, the average time required to complete a root cause analysis was 15½ hours, how much time should be allowed for the three that are expected next month?

49 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?

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

51 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?

52 Answers A.35 B.2 C.46½ hours ____________________________________ D. The ball costs 5p and the bat £1.05 E. 5 minutes F. 47 days

53 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)

54 Opening the Black Box

55 Evidence Based Medicine.. is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. …Increased expertise is reflected in many ways, but especially …in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. Sackett D,1996

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57 Background Influences Foreground Influences Clinical episode Clinical decision Clinical outcome Defences

58 CSA/Trainees in difficulty It’s all about…… Communication Skills Culture Clinical decision making

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60 Better is possible. It does not take genius, it takes diligence, it takes a clarity of purpose, it takes ingenuity, it takes a willingness to try.

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62 “Think as well as blink”?

63 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

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

65 “Think as well as blink”? Foreground factors Consider the unintended consequences of pursuing this diagnosis Use a systematic approach to common problems Acknowledge how the patient makes you feel Ask yourself: “What doesn’t fit? What can’t we explain?” Know when to Slow Down

66 “Think as well as blink”? Process factors: Cognitive forcing functions Diagnostic “timeout” Consider the opposite Consider the worst case Use “prospective hindsight”: look into the future and see what would happen if our diagnosis was wrong. Checklists

67 2 S “checklist” Summarising In order to summarise to the patient I have to work out what the story means Am I in the right system? what else could it be? what biases may be affecting me? what assumptions have I made? Safetynetting In order to safety net specifically I need to have considered: What else might happen? What if I am wrong? “Prospective Hindsight”: the final "regret filter" Both involve the patient

68 What to teach 121 The “content” Knowledge + language = discourse Debriefing “open the decision making box” CbDs SEAs Videos Joint surgeries Trigger videos eg Wessex CSA Encouraging: self awareness –decision making style/biases attitude to risk/own high risk situations

69 Other people’s suboptimal decisions are due to:- –Poor information –Lack of intelligence –Lack of experience –Personality flaws of individuals –Questionable motives

70 Our own suboptimal decisions are due to……….. Unforeseeable change in external factors


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