Decision making

1. Decision making • Satisficing 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

2. Mindlines “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, whichwere informed by brief reading, but mainly by their interactionswith each other and with opinion leaders, patients, and pharmaceuticalrepresentatives and by other sources of largely tacit knowledgethat built on their early training and their own and their colleagues'experience.”

4. Principles Decisions are processes, not events Tendency to view the decision as ok / not ok Probably more helpful to think about HOW we go about making decisions rather than WHAT decision should we make / has been made What 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)?

5. Context Ambient conditions Task difficulty Task ambiguity Affective state Modular responsivity TYPE 1 processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Rational override Dysrationalia override Calibration Diagnosis Repetition TYPE 2 processes NOT RECOGNIZED Intellectual Ability Education Training Critical thinking Logical competence Rationality Feedback

6. Rx Diagnosis

7. Consciously incompetent System 2 System 2 Assess Learn Consciously competent Unconsciously incompetent Practice Lapse System 1 System 1 Unconsciously competent

8. 2 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.

9. A caveat Biases 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 COMPLICATED BUT 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 expectation Availability bias – recent experience dominates evidence Bandwagon effect – we do it this way here Omission bias – natural disease progression preferred to those occurring due to action of physician Sutton’s slip – going for the obvious Gambler’s fallacy – I’ve seen 3 recently; this can’t be a fourth Search satisficing – found one thing, ignore others Vertical line failure – routine repetitive tasks leading to thinking in silo Blind spot bias – other people are susceptible to these biases but I am not

11. Was this patient handed off to me from a previous shift? Diagnosis momentum, framing Was the diagnosis suggested to me by the patient, nurse or another physician? Premature closure, framing bias Did I just accept the first diagnosis that came to mind? Anchoring, availability, search satisficing, premature closure Did I consider other organ systems besides the obvious one? Anchoring, search satisficing, premature closure is this a patient I don’t like, or like too much, for some reason? Affective bias Have I been interrupted or distracted while evaluating this patient? All biases Am I feeling fatigued right now? All biases Did I sleep poorly last night? All biases Am I cognitively overloaded or overextended right now? All biases Am I stereotyping this patient? Representative bias, affective bias,anchoring, fundamental attribution error, psych out error Have I effectively ruled out must-not-miss diagnoses? Overconfidence, anchoring, confirmation bias

12. Metacognition “The process by which we reflect upon, and have the option of regulating, what we are thinking” The Cognitive Imperative: Thinking about How We Think Croskerry 2000 Academic Emergency Medicine • standing back & observing our own thinking

13. Features of Metacognition Awareness of the learning process and the cognitive demands of a particular situation Recognition of the limitations of memory Ability to appreciate the broader perspective Capacity for self critique Ability to select a particular strategy for improving the decision making, particularly when things don’t fit

14. Cognitive Forcing Strategies For Improved Performance • Consider alternatives Routinely think: “if I am wrong what else might this be” ROWcS • Seek incongruent data Don’t be afraid to try and prove you are wrong • Reframe when recording Mentally reconsider meaning Reassess the associations YOU have created

15. Personal Strategies For Improved Performance 2 • Reconsider dissonant facts Take a step back from the problem • Know and understand test accuracy Tests are only so good Tests are only as good as the questions you ask of them • Use time as a diagnostic tool Careful, watchful, wait and see is NOT the same as inactivity

16. Personal Strategies For Improved Performance 3 • Decrease reliance on memory Use cognitive aids (but use them wisely): Decision support, mnemonics, guidelines, algorithms etc. • Try to make tasks easier e.g. Calculate drug doses on paper (not in your head)

17. Personal Strategies For Improved Performance 4 • Be aware of own affective state Especially time pressures • Be aware of our decision mode • Establish accountability in a given situation Who is doing what? Who is responsible for what? • Non-judgemental, constructive feedback Be a giver; be a welcoming receiver