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

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

“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.”

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)?

Context Ambient conditions Task difficulty Task ambiguity Affective state

Modular responsivity

Intellectual AbilityEducationTrainingCritical thinkingLogical competenceRationalityFeedback

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride

Calibration DiagnosisPatientPresentation

PatternProcessor

RECOGNIZED

TYPE

11processes

TYPE

22processes

NOTRECOGNIZED

DiagnosisDiagnosis RxRx

Consciously competent

Learn

Unconsciously competent

PracticeLapse

Unconsciously incompetent

Consciously incompetent

AssessSystem 2System 2

System 1System 1System 1System 1

System 2System 2

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.

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.

>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

• 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

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 ThinkCroskerry 2000 Academic Emergency Medicine

• standing back & observing our own thinking

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

Cognitive Forcing Strategies For Improved Performance

• Consider alternativesRoutinely think: “if I am wrong what else might this be”

ROWcS

• Seek incongruent dataDon’t be afraid to try and prove you are wrong

• Reframe when recordingMentally reconsider meaning

Reassess the associations YOU have created

Personal Strategies For Improved Performance 2

• Reconsider dissonant factsTake 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 toolCareful, watchful, wait and see is NOT the same as

inactivity

Personal 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)

• Be aware of own affective stateEspecially time pressures

• Be aware of our decision mode• Establish accountability in a given

situationWho is doing what?

Who is responsible for what?

• Non-judgemental, constructive feedbackBe a giver; be a welcoming receiver

Personal Strategies For Improved Performance 4