Presentation on theme: "Decision making Satisficing is a decision-making strategy that entails searching through the evidence and available alternatives until an acceptability."— Presentation transcript:
1Decision makingSatisficing is a decision-making strategy that entails searching through the evidence and available alternatives until an acceptability threshold is met (the level of uncertainty has been reduced to a level at which the individual feels comfortable to make a decision). This is contrasted with optimal decision making, an approach that specifically attempts to find the best alternative available
2Mindlines“Clinicians rarely accessed, appraised, and used explicit evidence directly from research or other formal sources; rare exceptions were where they might consult such sources after dealing with a case that had particularly challenged them.”Gabbay and le May. BMJ 2004; 329: 1013–1016
3“Instead, they relied on what we have called "mindlines,” collectively reinforced, internalised tacit guidelines, which were informed by brief reading, but mainly by their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives and by other sources of largely tacit knowledge that built on their early training and their own and their colleagues' experience.”
4Principles Decisions are processes, not events Tendency to view the decision as ok / not okProbably more helpful to think about HOW we go about making decisions rather than WHAT decision should we make / has been madeWhat is system 1 telling me, do I need to work it out with system 2, am I at risk of a cognitive or affective bias in system 1, am I missing something (calibration)?
51 2 Calibration Diagnosis TYPE Context Modular responsivity Ambient conditionsTask difficultyTask ambiguityAffective stateModular responsivityIntellectual AbilityEducationTrainingCritical thinkingLogical competenceRationalityFeedbackPattern RecognitionRepetitionRationaloverrideDysrationaliaCalibrationDiagnosisPatientPresentationPatternProcessorRECOGNIZEDTYPE1processes2NOTNealHow can dual process models mitigate diagnostic error?A single model that explains the wide variety of decisions that are made is a major simplificationThe specific operating characteristics of the model can be tested in particular clinical situationsThe model can be readily taught to learners across a wide range of disciplinesUnderstanding the model allows more focused metacognitionThe described features of the model can generate specific research questions about decision making processes in particular situationsCroskerry 20095
7Consciously incompetent System 2System 2AssessLearnConsciously competentUnconsciously incompetentPracticeLapseSystem 1System 1Unconsciously competent
82 ways to improve our performance Alerting the analytical mode to situations in which a bias might arise so that it can be detected and an intervention applied.Mitigate the impact of adverse ambient conditions, either by improving conditions in the decision making environment, or by changing the threshold for detection of bias.
9A caveatBiases have multiple determinants, and it is unlikely that there is a ‘one-to-one mapping of causes to bias or of bias to cure;Neither is it likely that one-shot debiasing interventions will be effective.It’s COMPLEX, not COMPLICATEDBUT People quite often change their minds and behaviours for the better.
10>50 cognitive biases Anchoring bias – early salient feature Ascertainment bias – thinking shaped by prior expectationAvailability bias – recent experience dominates evidenceBandwagon effect – we do it this way hereOmission bias – natural disease progression preferred to those occurring due to action of physicianSutton’s slip – going for the obviousGambler’s fallacy – I’ve seen 3 recently; this can’t be a fourthSearch satisficing – found one thing, ignore othersVertical line failure – routine repetitive tasks leading to thinking in siloBlind spot bias – other people are susceptible to these biases but I am not
11Was this patient handed off to me from a previous shift Was this patient handed off to me from a previous shift? Diagnosis momentum, framingWas the diagnosis suggested to me by the patient, nurse or another physician? Premature closure, framing biasDid I just accept the first diagnosis that came to mind? Anchoring, availability, searchsatisficing, premature closureDid I consider other organ systems besides the obvious one? Anchoring, search satisficing, premature closureis this a patient I don’t like, or like too much, for some reason? Affective biasHave I been interrupted or distracted while evaluating this patient? All biasesAm I feeling fatigued right now? All biasesDid I sleep poorly last night? All biasesAm I cognitively overloaded or overextended right now? All biasesAm I stereotyping this patient? Representative bias, affective bias,anchoring, fundamental attribution error, psych out errorHave I effectively ruled out must-not-miss diagnoses? Overconfidence, anchoring, confirmation bias
12Metacognition“The process by which we reflect upon, and have the option of regulating, what we are thinking”The Cognitive Imperative: Thinking about How We ThinkCroskerry Academic Emergency Medicinestanding back & observing our own thinking
13Features of Metacognition Awareness of the learning process and the cognitive demands of a particular situationRecognition of the limitations of memoryAbility to appreciate the broader perspectiveCapacity for self critiqueAbility to select a particular strategy for improving the decision making, particularly when things don’t fitSimon13
14Cognitive Forcing Strategies For Improved Performance Consider alternativesRoutinely think: “if I am wrong what else might this be”ROWcSSeek incongruent dataDon’t be afraid to try and prove you are wrongReframe when recordingMentally reconsider meaningReassess the associations YOU have createdKurt/SimonClinical examples14
15Personal Strategies For Improved Performance 2 Reconsider dissonant factsTake a step back from the problemKnow and understand test accuracyTests are only so goodTests are only as good as the questions you ask of themUse time as a diagnostic toolCareful, watchful, wait and see is NOT the same as inactivityKurt/SimonClinical examples15
16Personal Strategies For Improved Performance 3 Decrease reliance on memoryUse cognitive aids (but use them wisely):Decision support, mnemonics, guidelines, algorithms etc.Try to make tasks easiere.g. Calculate drug doses on paper (not in your head)Kurt/SimonClinical examples16
17Personal Strategies For Improved Performance 4 Be aware of own affective stateEspecially time pressuresBe aware of our decision modeEstablish accountability in a given situationWho is doing what?Who is responsible for what?Non-judgemental, constructive feedbackBe a giver; be a welcoming receiverKurt/SimonClinical examples17