Information, choices & professional judgement: Information, choices & professional judgement: what’s right, wrong and can be done with what’s right, wrong and can be done with decision making in the health professions.decision making in the health professions.

Dr Carl Thompson, Department of Health Dr Carl Thompson, Department of Health Sciences, University of York, UKSciences, University of York, UK

Alberta Heritage Foundation for Medical Alberta Heritage Foundation for Medical Research Visiting ScholarResearch Visiting Scholar

What are we talking about?What are we talking about?

Not tasks and not activity Not tasks and not activity per seper se

The weighting of information The weighting of information (professional judgement) (professional judgement)

Using these weighed pro’s and con’s Using these weighed pro’s and con’s to make choices (clinical decisions)to make choices (clinical decisions)

Why worry about decision Why worry about decision making and judgement?making and judgement?

They contribute to They contribute to health gainhealth gain Mortality and morbidityMortality and morbidity Professional powerProfessional power Patient involvementPatient involvement

Decisions and Judgements are the Decisions and Judgements are the ‘black box’ in healthcare.‘black box’ in healthcare.

Boundaries and the ball park are Boundaries and the ball park are shiftingshifting

Cognitiveinputs

Organisational factors

Social factors

Patientvalues

As well as:

Resources

Research knowledge

Uncertainty

Policy

Time

Control over decision elements

The good newsThe good news

Given conditions of Given conditions of irreducible irreducible uncertainty most decisions are good uncertainty most decisions are good enoughenough

People apply the same rules to People apply the same rules to professional decision making as they professional decision making as they do in real life – this is a good thing!do in real life – this is a good thing!

The Bad NewsThe Bad News

Within Within unavoidable unavoidable events in events in healthcare are healthcare are avoidable avoidable eventsevents

Cognitive shortcuts lead to Cognitive shortcuts lead to systematic errors…systematic errors…

Simply relying on clinical experience Simply relying on clinical experience is not enoughis not enough

Does bad judgement matter?Does bad judgement matter? USAUSA 44-98,000 deaths – “To Err is 44-98,000 deaths – “To Err is

Human”Human” Australia Australia 250,000 adverse events250,000 adverse events

50,000 permanent disability50,000 permanent disability

10,000 deaths “Iatrogenic Injury in 10,000 deaths “Iatrogenic Injury in Australia”Australia”

DenmarkDenmark confirmed 9% of admissionsconfirmed 9% of admissions N.Z. N.Z. confirmed 10% of admissionsconfirmed 10% of admissions UKUK 11% of admissions11% of admissions

850,000 adverse events850,000 adverse events

deaths & permanent disabilitydeaths & permanent disability

Between 7 and 8.4 additional bed days per adverse eventBetween 7 and 8.4 additional bed days per adverse event

Why do they happen…Why do they happen…Was there a prior intention to act?

Was there intention in action?

Involuntary or no intentional action

Spontaneous or subsidiary action

Did the actions proceed as planned?

Unintentional action (slip or lapse)

Did the actions achieve their desired end? Intentional but

mistaken action

Successful action

NoNo

No

No

Yes

Yes

Yes

Yes

What can be doneWhat can be done

More sophisticated maps of the More sophisticated maps of the ‘black box’‘black box’

Develop what we know works Develop what we know works

Decision supportive technologiesDecision supportive technologies

Education and training in handling Education and training in handling uncertaintyuncertainty

ANALYSIS

INTUITIONQuality Of intuition

Quality Of Analysis

Least Precise/explicit

Definition of conceptsSpecification of relationshipsMeasurement of magnitudes

most Precise/explicit

MODE “7” 6 5 4 3 2 1KNOWLEDGE non- clinical expert descriptive case randomised scientificGENERATION cognitive judgement consensus (positive) control controlled experiment

“judgement” judgement model study trial

DECISION non-cognitive clinical expert decisionMAKING “decision” judgement consensus (normative)

decision model © dowie2002

Social judgement modellingSocial judgement modelling

Example: shockExample: shock

www.york.ac.uk/res/dec/shockwww.york.ac.uk/res/dec/shock 20 cue profiles in orthogonal design20 cue profiles in orthogonal design BP, Pulse, Resps, Urine Output, GCS.BP, Pulse, Resps, Urine Output, GCS. 3 levels (abnormal, normal, equivocal)3 levels (abnormal, normal, equivocal) Left side from regression of 100 cases in Left side from regression of 100 cases in

ITUITU 45 students pre-post intervention 45 students pre-post intervention

(lecture and web-based teaching (lecture and web-based teaching materials – targeted)materials – targeted)

Individual Subject Utilities

glasgow coma score

abnormalequivocalnormal

Util

ity20

10

0

-10

-20

31.00

32.00

33.00

34.00

35.00

36.00

37.00

38.00

39.00

40.00

42.00

43.00

Individual Subject Utilities

glasgow coma score

abnormalequivocalnormal

Util

ity20

10

0

-10

-20

23.00

25.00

27.00

29.00

30.00

31.00

32.00

33.00

35.00

40.00

42.00

43.00

Importance summary

Factor

glasgow coma score

urine output

oxygen sats

resps

pulse

systolic BP

Ave

rag

ed

Im

po

rta

nce

30

20

10

0

11

19

15

25

14

16

Using (refining and evaluating) Using (refining and evaluating) effective interventionseffective interventions

Multifaceted interventions (combine 2 or Multifaceted interventions (combine 2 or more of audit and feedback, reminders, more of audit and feedback, reminders, local consensus processes, marketing)local consensus processes, marketing)

Interactive educational meetings Interactive educational meetings

RemindersReminders

Educational outreach visitsEducational outreach visits

Decision supportDecision supportFunction Example

Alerting Highlighting out of range (either too high or too low laboratory values)

Reminding Reminding the clinician to schedule a cervical smear

Critiquing Rejecting an inappropriate order for a new drug

Interpreting Analysing an electrocardiogram

Predicting Calculating the risk of mortality from a severity of illness score

Diagnosing Listing a differential diagnosis for a patient with chest pain

Assisting Tailoring the antibiotic choices for patients with STDs

Suggesting Generating suggestions for adjusting a mechanical ventilator in an Intensive Therapy Unit.

Facilitating Providing a forum for interaction, model building and joint negotiation of treatment.

Better educationBetter education

Right knowledge for professional Right knowledge for professional activity?activity?

A Role for learning new ‘languages’:A Role for learning new ‘languages’: Collecting and interpreting evidence (statistics; Collecting and interpreting evidence (statistics;

information science)information science) Dealing with uncertainty (probability theory)Dealing with uncertainty (probability theory) Making decisions (economics and decision Making decisions (economics and decision

theory)theory)

‘‘Accept the fact of uncertainty and Accept the fact of uncertainty and learn to live with it. Since no magic learn to live with it. Since no magic will provide certainty, our plans must will provide certainty, our plans must be made without it’: Roberta be made without it’: Roberta Wohlstetter (1962)Wohlstetter (1962)

‘‘There is nothing more profitable for a There is nothing more profitable for a person than to take good counsel person than to take good counsel with oneself; for even if the event with oneself; for even if the event turns out contrary to one’s hopes, still turns out contrary to one’s hopes, still one’s decision was right’: Herodotusone’s decision was right’: Herodotus