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Understanding the Science of Decision Making and How it Influences Healthcare Providers

Posted on Tue, Dec 23, 2014
Understanding the Science of Decision Making  and How it Influences Healthcare Providers

How do physicians and other healthcare professionals make decisions about caring for their patients? What factors influence their decision-making process and is there more to it than experience and evidence-based practices? Adam R. Corley, MD, FACEP, vice president and regional medical director for EmCare’s west division, explored this topic in his presentation "Introduction to Decision Science for Healthcare Providers" at EmCare’s 2014 annual leadership conference.

By TOM PECK

Currently, everyone in healthcare is focused on outcomes – outcomes from care and treatment decisions made by physicians and other. Dr. Corley pointed out that while significant resources are being invested in improving outcomes, little attention is being paid to how decisions are made and the processes involved in making those decisions.

Dr. Corley’s presentation was designed to help attendees gain a better understanding of:
 

  • The field of decision science

  • How cognitive bias and heuristics affect decision making

  • When intuitive judgment is useful

  • The checklist debate

  • Choice architecture

  • Where to learn more about the topic of decision science.


Daniel Kahneman and Amos Tversky are credited with being the fathers of decision science, having established a cognitive basis for common human errors which arise from heuristics and biases. Kahneman was awarded the Nobel Memorial Prize in Economic Sciences in 2002 for his work in prospect theory. How does this work apply to decision making in healthcare?

The Department of Health Policy & Management at the Harvard School of Public Health uses the following explanation:

"We make decisions every day, usually without much thought about how we make them. An intuitive, personal approach works fairly well when we’re deciding whether we’re going to have eggs or cereal for breakfast, but we may very well overlook important considerations and possibilities when it comes to more complex decisions."

This is particularly true of the complex decisions often required of policy makers such as trying to determine the best use of drugs or technologies to prevent or treat heart disease or a health-care payer trying to decide which of the expensive but effective cancer therapies available should be offered to patients if funds are limited? For these kinds of questions—high-impact questions that involve uncertainty, risk, several possible perspectives, and multiple competing objectives—we may try using rules of thumb or panels of experts, but even these approaches can easily bypass optimal choices.

Merely keeping all the variables in mind is beyond human capacity; analyzing them effectively is even more unmanageable. Decision science steps into the breach by providing structure and guidance for systematic thinking about these kinds of questions based on logical principles, and informed by what we know about the limitations of human judgment and decision-making in complex situations, it allows logical and consistent analysis of the tough, complex decisions often faced by public health providers1.

To understand the process of decision-making, it is necessary to understand the role of the heuristic. A heuristic is a simple procedure that helps find adequate, though often imperfect answers to difficult questions. It is a mental shortcut created by the brain to help understand complex information. Dr. Corley cited the example of a physician initially encountering a 70-year-old patient in bed with chest pain. In all likelihood, the physician’s mind has automatically formulated what to do with the patient – admit him or her. This heuristic can take the physician down the wrong path and lead him or her to wrong decisions for the patient. It can also lead to cognitive bias, a pattern of deviation in judgment, whereby inferences about other people and situations may be drawn in an illogical fashion, sometimes leading to irrationality.Representative heuristic is the likelihood of an event estimated using a prototype that already exists in our mind. It is used when making judgments about the probability of an event under uncertain conditions. Dr. Corley cautioned that the fact that something seems more representative does not make it more likely.

Anchoring also factors into decision making. Anchoring is the tendency to rely too heavily on the first piece of information offered when making decisions. Once the anchor is set, other judgments are made by adjusting away from the anchor. Adjustments are made based on additional information but are usually insufficient, giving the initial anchor a great deal of influence over future assessments. Anchoring can be subconscious. The important thing to recognize, Dr. Corley pointed out, is that someone has offered you an anchor and how that might influence your opinion or decision.

The framing effect is a common phenomenon in healthcare decision making. It involves drawing different conclusions from the same information, depending on how or by whom the information is presented. Dr. Corley cited the example of a case being presented to an emergency department physician and how the presenter -- EMS, APP, resident or colleague – can frame the facts differently based on his or her role. It is important for the ED physician to understand the framer’s bias as he or she evaluates the evidence upon which a decision will be made about the patient.

The availability heuristic is the tendency to overestimate the likelihood of events with greater availability in memory. The degree of bias can depend on how recent the memories are or how unusual or emotionally charged they may be. Dr. Corley also cited the clustering illusion as influencing decision making. This is the tendency to see phantom patterns in random data. He used an example familiar to many in the room – when a staff member mentions how quiet it has been on the unit and everyone expects that this observation will somehow cause things to become very busy.

Dr. Corley also highlighted confirmation bias, the tendency of people to favor information that confirms their beliefs or hypotheses, and information bias, the tendency for people to seek information even when it cannot affect action.

Choice architecture is similar to framing. It describes the way that decisions may and can be influenced by how the choices are presented. Every decision we make has a default choice, Dr. Corley pointed out. The default choice is generally very powerful. He flashed a red stop sign with the word "Go" on it as an example. He also cited the example of organ donation and how consent was handled differently in Germany and Austria. In Germany, healthcare providers used explicit consent where the individual opts into the process by checking a box. The result was that only 12 percent agreed to organ donation. In Austria, individuals opt out of donation by checking a box. This is implied consent and the result was that 95 percent agreed to organ donation.

Electronic health records are changing the way physicians and others document their care decisions. Rather than the traditional method of charting in narrative fashion, EHRs are forcing caregivers to check boxes, resulting in choice architecture problems.

Checklists, a concept originated in the airline industry, have not been widely accepted or appreciated in medicine, even though there is mounting evidence about their value. A good example is a 2002 study conducted at Johns Hopkins that examined central line infection rates. The observational study outlined steps involved in placing and caring for a central line. Researchers discovered that in one out of three cases, a best-practice step was skipped, resulting in higher infection rates. When a checklist was created, it provided a structure to make sure all steps were followed. The infection rate dropped to zero.

Finally, Dr. Corley asked attendees whether intuitive judgment is useful or reliable in decision making. He used the example of fire captains. When faced with a particular situation, the captains were quick to narrow their choices to one or two in terms of how they approached fighting the fire. Experience and training are keys to using intuitive judgment to make good decisions. Rapid and immediate feedback is also important.

1Institute for Technology Assessment



 

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