The multiple facets of physician decision-making under uncertainty

1. The multiple facets of physician decision-making under uncertainty Katharina Janus, Ph.D. Harkness Fellow in Health Care Policy Department of Health Policy and Management Columbia University, New York Orlando, June 2007

2. Overview • Rationale for the project • Objectives • Methodology • Preliminary findings • Implications for policy, delivery and practice in the U.S. and Germany

3. 1 (69%) 2 (31%) 3 (7%) 4 (.6%) 5 (.002%) 6 (.00003%) Untrustworthy Quality of Care Sources: modified from C. Buck, GE; Dr. Sam Nussbaum, Wellpoint; & Mark Sollek, Premera IRS Phone-in Tax Advice Overall Health Care Quality in U.S.(Rand Study 2003) Defects per million Airline baggage handling Fair Reliability U.S Airline flight fatalities/ U.S. Industry Best of Class NBA Free-throws High Reliability ∑ level (% Defects)

4. Quality Vision for P4P Programs in the U.S. Long-Term Goals Value Improve Member Health Short-Term Goals Outcomes Foundation Structure / Process Build Trust / Collaboration Source: Nussbaum P4P Summit 2006

5. Limitations and challenges of P4P • Ceiling effects (high versus low performers) • Organizational scale (small practices) • Costs (too early to tell???) • Quality (some positive evidence…) • Caveats (selection bias, definition of measures, loss of holistic approach to care, socio-demographic fine-tuning) Janus, K., Brown, L.D. (2007), Medicare as Incubator for Innovation in Payment Policy, Journal of Health Politics, Policy and Law, vol. 32, no.1: 293-306.

6. A new approach is needed… • Because • specialties are faced with significantly different decision-making situations, have different cultures and, thus, respond differently to incentives • a large part of medical decision-making does not refer to routine treatment decisions, but rather to adhoc situations that are not standardizable and underlie a high degree of uncertainty • Because one size does not fit all!

7. Overview • Rationale for the project • Objectives • Methodology • Preliminary findings • Implications for policy, delivery and practice in the U.S. and Germany

8. Objectives • What are the challenges of a physician operating under high uncertainty in a system? • Are there general decision-making patterns of physicians in case of unexpected events and what do they look like? • How do physicians manage prospectively uncertainty and the potential for error in their daily work life? • What is the role of informal organization (e.g. event discussions in the hallway) when dealing with unexpected events? Could/Should it be more formalized and structured? • Building on the derived decision-making patterns, how can the ‘unpredictable’ be made more ‘predictable?’ What do ‘guidelines’ for unexpected events look like? What is the role of the human and what is the role of the system component in these guidelines? How can we incentivize these guidelines? • How can the strategies be implemented?

9. Overview • Rationale for the project • Objectives • Methodology • Preliminary findings • Implications for policy, delivery and practice in the U.S. and Germany

10. Methodology • Physicians from four specialties (surgery, general internal medicine, anesthesiology and psychiatry) have been recruited for qualitative interviews at New York Presbyterian Hospital and Weill/Cornell Medical Center. • These four specialties represent a useful continuum for the degree of treatment processes that are considered to be ‘routine’ and non-routine. • Interviews were conducted face-to-face and were tape-recorded, transcribed and evaluated using a content management software. • 40 interviews are currently in the database. Further will follow.

11. Overview • Rationale for the project • Objectives • Methodology • Preliminary findings • Implications for policy, delivery and practice in the U.S. and Germany

12. Uncertainty in decision-making versus frequency of events across specialties Frequency of Unexpected Events Uncertainty in Decision- Making Anesthesia Surgery Internal Medicine Psychiatry

13. Stages of decision-making under uncertainty Prospective Decision- Making Actual Decision- Making Retrospective Decision- Making Human Component Learning Support Reporting System Component

14. Prospective decision-making • Resources • Articles, textbooks and the internet • Colleagues and advisors • Equipment and pharmaceuticals • Patient information and patient engagement • Reflection and experience • Risk assessment and prioritizing • Acceptance of the “Random“

15. Actual decision-making • Resources • Articles, textbooks and the internet • Colleagues and advisors • Equipment and pharmaceuticals • Patient information and patient engagement • Reflection and experience • Prioritizing under constraints • Stress

16. Retrospective decision-making – how to deal with events • Formal processes for the unexpected • Informal processes for the unexpected • Informal human interaction in general • Physician culture in particular • Blame/shame • Accountability • Reciprocity/ mutual protection • Detachment • Openness to failure

17. System Factor – example MERS(Medical Event Reporting System) • General reporting obligation (self/professionalism, patient, organization) • Incentives for reporting or not reporting • Anonymity • Benchmarking • Connectivity and work process integration • Cost • Culture • Definition of events • External professional organization • Feedback/ Information access • Immediate staff/technical support • Litigation • Medical training • Monetary incentives • Organizational accountability • Paperwork/time • Personal accountability • Threats by the organization • Usability/tutorial • Reporting value for specialties

18. Overview • Rationale for the project • Objectives • Methodology • Preliminary findings • Implications for policy, delivery and practice in the U.S. and Germany

19. Implications and Learnings • Before designing incentive systems we have to understand physician decision-making. • Managed care (Standard Operating Procedures) does not apply to decision-making under uncertainty. • But: Unexpected events derive from intrinsic uncertainty. • Errors in medicine are not only a system problem, the physician factor is crucial. Managing uncertainty has its own challenges. • But: Systems can support physician decision-making in different ways to enhance quality of care.

20. “The practice of medicine is an art based on science“ Sir William Osler

21. Thank you very much for your attention! Special thanks go to: Lola Adedokun David Blumenthal Alexander Bock Larry Brown Michael Gaitanides Annetine Gelijns Sherry Glied Jack Rowe Tom Rundall Shoshanna Sofaer Mario Weiss …and The Commonwealth Fund!