1. Intuition, Rapid Response Teams and Mentoring Thomas A. Iannucci, M.D., FACOG Department of Maternal-Fetal Medicine Advocate Lutheran General Hospital

2. Making Decisions Decision-making is commonly described as a multistage process – Define a problem – Generate alternatives – Evaluate options (possible formal analytical methods) – Choice – Implement decision

3. Making Decisions How does intuition work when making decisions? – Assess situationcome to a solution – No comparison of alternatives – Referring to Critical, Complex decisions, not simple What are we using in these cases?: – Sixth sense – Intuition – Gut

4. Making Decisions What is intuition? Is it just there? Can we improve our intuition? – To improve it we need to better understand how intuition works Can we actually harness and enhance our intuition to become better decision makers? Can we share our intuition?

5. Making Decisions Gary Klein, PhD-psychologist researching decision-making Asked fire commanders about making life and death decisions When questioning how they made difficult decisions, he concluded they frequently resorted to intuition.

6. Intuition in Decisions He asked fire commanders about their most challenging situations – One commander stated that E.S.P. played a role in a particular situation – He firmly believed that he had experienced extra sensory perception…

7. Intuition in Decisions Situation: – The commander’s crew had arrived at a fire that appeared to be a simple contained, kitchen fire. – The fire however was not responding to the direct water spray from the living room – He also noted that the fire was much hotter than expected – His “sixth sense” then kicked in – He pulled his crew completely out of the house

8. Intuition in Decisions Soon after they left the house the living room floor collapsed…

9. Intuition in Decisions Klein then asked him why he made the decision to pull the crew out – He was surprised that the water had no effect on a seemingly small fire – He was puzzled at how hot the fire was – He thought it seemed odd at how quiet the fire was from the living room

10. Intuition in Decisions His explanation was summarized by Klein: – He pattern he saw did not fit – The situation violated his expectations – Frankly, he wasn’t sure what was going on

11. Intuition in Decisions Overall, our experiences provide us with an expected set of patterns. – Intuition is fundamentally a pattern recognition process We use our expectations of these patterns to match with a given situation At times we cannot always verbalize what is wrong when these patterns don’t match, but we innately know that the pattern doesn’t match.

12. Intuition in Decisions In follow-up studies Klein studied other professions including: – Military commanders – Pilots – Nurses He found that intuition played a powerful role in how experts in all fields “sized up" a situation and made decisions.

13. Intuition in Decisions Intuition is fundamentally a pattern recognition process – The patterns are formed from past experience – The process occurs very quickly – Unlike other decision-making processes we don’t think through a series of alternatives

14. Intuition in Decisions Intuition gradually develops as someone gains a deep expertise in a specific field More situations lead to an increased ability to recognize and match patterns The thought is that while we are not always aware of it our mind is always searching for patterns for all situations that we encounter We use pattern recognition to spot problems and quickly guide us to solutions

15. Intuition and RRT’s Klein interviewed many nurses and physicians in his study of intuition – He realized that these professionals frequently use intuition to make decisions – The patterns we look for are those assembled from: Vital signs, laboratory data, symptoms, physical findings, and in obstetrics electronic fetal monitoring

16. Intuition and RRT’s There was a clear distinction between novices and experts and their ability to match patterns He often found that with experience nurses and physicians often sensed something wasn’t right before the data became clear How can we use this to improve patient care?

17. Intuition and RRTs Studies in England in the late ‘90s showed that in the hours before a patient had a cardiac arrest or other serious problems there were subtle signs of deterioration Efforts were made to find ways of detecting these changes more proactively Their interviews of many nurses after critical events occurred

18. Intuition and RRTs Discussions with nurses often lead to the realization that these nurses knew something wasn’t right and they had “a feeling” that things were turning for the worse This led to the development of rapid response teams

19. Intuition and RRTs Rapid response teams are mean to lead to an evaluation of the patient prior to them reaching a critical situation This is distinctly different than code teams which are called after a critical situation is reached – This distinction is critical!!

20. Intuition and RRTs The 100,000 Lives Campaign is a nationwide initiative launched by the Institute for Healthcare Improvement (IHI) to significantly reduce morbidity and mortality in American health care. Deploy Rapid Response Teams…at the first sign of patient decline

21. Intuition and RRTs Based on research showing that patients often exhibit signs and symptoms of increasing instability for several hours prior to a cardiac arrest — changes in breathing, heart rate, or mental status, for example — the idea is to rescue patients early in their decline before a crisis occurs.

22. Intuition and RRTs The Rapid Response Team intervenes upstream from a potential code situation, relying on bedside nurses who are highly sensitive to signs that a patient’s condition is deteriorating, and empowered to call others into action. Intuition is fundamentally a pattern recognition process – The patterns are formed from past experience – The process occurs very quickly – Unlike other decision- making processes we don’t think through a series of alternatives

23. Intuition and RRTs Technical skills: Adult advanced cardiac life support certification Pediatric advanced life support certification Critical care experience Critical thinking Assessment and diagnostic abilities Ability to communicate concisely Ability to recognize when they are unable to meet the patient's needs

24. Intuition and RRTs – The attitude of the team members toward the bedside staff, patient and families has a direct link to the overall success of the rapid response team program. – It is imperative for the responders to keep in mind that "all rapid response team calls are warranted." – If the bedside staff member does not feel respected and appreciated, or is intimidated by the responding staff, he/she may be reluctant to call the rapid response team in the future. Rapid Response Team. Third Edition/May 2009

25. RRTs- other benefits Experts and novices at bedside together People tend take the opportunity to share their intuition with others Through discussion of the case, experts can help develop the intuition of novices

26. RRTs- other benefits Bedside patient discussions with the entire team present allows a level of teaching that cannot be accomplished in a classroom

27. Passing on of Wisdom The definition of apprenticeship Socrates-the Socratic method – a form of inquiry and debate between individuals with opposing viewpoints based on asking and answering questions to stimulate critical thinking and to illuminate ideas – It is a dialectical method, often involving an oppositional discussion in which the defense of one point of view is pitted against the defense of another

28. Passing on of Wisdom Thinking out loud – A key practice to use at bedside Literally, talking through a thought process Not to be confused with second guessing yourself Explanations must be reassuring

29. Passing on of Wisdom Thinking out loud – I’m doing this for the patient because… – I’m looking at this data because… – I’m concerned about this patient because… – Why does this change in vital signs concern me…

30. Passing on of Wisdom Thinking out loud – Using this process experts can share how they develop intuition – Thought processes going on in the mind of an expert – An optimal form of mentoring

31. Passing on of Wisdom Mentoring – Mentoring is ultimately how intuition is optimally shared and developed – It requires Astute observation by the mentor and the student Astute listening by the inexperienced Empathy by the mentor Excellent communication skills by the mentor

32. Passing on of Wisdom Pitfalls of using intuition – Misuse of analogy He picked the wrong analogy – Can make the wrong match to the situation Picked the wrong pattern – Overly complex situation Complexity of the situation can obscure pattern recognition “Too much noise” Too many patterns or can’t see the most important pattern Outdated mental models- New data causes out dating of information. Keeping up with new information

33. Passing on of Wisdom Pitfalls of Mentoring People need to understand your rationale and your intent in order to apply knowledge themselves Communicate your intuition, get feedback Ensure alignment- – Make sure what you want them to do and what they think you want them to do are the same

34. Passing on of Wisdom Five steps: 1)Here is what I think is going on 2)Here is what I think we should do 3)This is why/my rationale 4)Here is what we need to watch for 5)Tell me what you think Tell what you understand of what I said Are there any issues with my thinking?

35. Conclusion There is a link between intuitive thinking, the theory behind rapid response teams and how we can mentor less experienced members of our team Optimal thought processes and teaching are best done using a combination of intuition and analytical thinking

36. Bibliography Roberto, MA. The Art of Critical Decision Making. Chantilly, VA: The Teaching Company, 2009. Client, G. Sources of power: How People Make Decisions. Cambridge MA: MIT Press, 1999. Gladwell, M. Blink: The Power of Thinking Without Thinking. 2005. Healthcare Protocol: Rapid Response Team. Institute for Healthcare Clinical Improvement. Third ed., May 2009 Institute for Healthcare Improvement. Rapid response information. Online