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Clinical decision making
Carl ThompsonUK, Centre for Evidence Based Nursing
Editor, Evidence Based Nursing
www.ebn.bmj.com
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This session
Integrating research evidence with preferences and contextual informationThe ways people think and make choices
When should intuition and more structured approaches be used?What’s right and wrong with clinical
experience?Tools and techniques: decision analysis,
cognitive approaches
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How do nurses (and doctors) think they think?
1. Make sense of multiple cues
2. Diagnose or assess3. Treat or intervene4. Evaluate progress5. Treat some more if
needed
Errr… start again…
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How do they actually think?
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The theory – cognitive continuum
Hamm,R (1988) in Dowie & Elstein, Clinical Judgement and decision making, Cambridge University Press
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Daniel Kahneman and Amos Tversky (d. 1996) Tversky and Kahneman, Judgment Under Uncertainty: Heuristics and Biases, Science (1974), Vol. 185, pp 1124-1131
Heuristics and Bias
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The Need to Assess Probabilities
People need to make decisions constantly: diagnosis and therapy
Thus, people need to assess probabilities to classify objects or predict various values, such as p (DISEASE|SYMPTOMS)
People employ heuristics to assess probabilities heuristics lead to significant biases,
CONSISTENTLY This observation leads to a descriptive, rather than a
normative, theory of human probability assessment
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“Getting” healthcare is not easy
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Pattern recognition is easier if you have experience
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Experience: A problem of perceptionSlide from Slawson, Shaughnessy, Becker, 1999.
Do you see the Dalmation in the picture? Moral: Clinical experience sometimes helps see, sometimes prevents seeing the right pictureNow that you see it, can you try to not see it?Moral: Experience can result in ideas that are difficult to change
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One learns the basic patterns
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One sees them in new situations.
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Then one can see the pattern where before it had been confusing.
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Time and nursing decisions
Once every 30 seconds in critical care (Bucknall, 2000)
Circa 50 decisions every 8 hour shift in Medical Admissions (Thompson et al. 2001 – 2005)
5 judgement or decision challenges per consult for health visitors.
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Remember uncertainty?
How do we normally respond? Experiential/internal knowledge Very limited textual information use and for certain
kinds of decisions (British National Formulary and local protocols)
90 hours of primary care = 1 telephone call 180 hours of acute care (1080 decisions) = local protocols
x4 times, BNF x50 times).
‘sophistication’ and technology doesn’t matter (Randell et al. 2007).
Demography and biography poor predictors of use
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The five classic decision pitfalls
Representativeness and base rate neglect
AvailabilityOverconfidenceConfirmationIllusory correlations
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What can we do?
Think about decision structure, time & visibility Be aware of base rates Consider whether information is truly relevant
and not just salient Seek reasons why you may be wrong and
entertain alternatives Ask questions that may disprove, rather than
confirm, your current hº You are wrong more often than you think