Intuition, Rapid Response Teams and Mentoring

Thomas A. Iannucci, M.D., FACOG Department of Maternal-Fetal Medicine

Advocate Lutheran General Hospital

Making Decisions

• Decision-making is commonly described as a multistage process– Define a problem– Generate alternatives– Evaluate options (possible formal analytical

methods)– Choice– Implement decision

Making Decisions

• How does intuition work when making decisions?– Assess situation come to a solution– No comparison of alternatives– Referring to Critical, Complex decisions, not simple

• What are we using in these cases?:– Sixth sense– Intuition– Gut

Making Decisions

• What is intuition? • Is it just there?• Can we improve our intuition?– To improve it we need to better understand how

intuition works

• Can we actually harness and enhance our intuition to become better decision makers?

• Can we share our intuition?

Making Decisions

• Gary Klein, PhD-psychologist researching decision-making

• Asked fire commanders about making life and death decisions

• When questioning how they made difficult decisions, he concluded they frequently resorted to intuition.

Intuition in Decisions

• He asked fire commanders about their most challenging situations– One commander stated that E.S.P. played a role in

a particular situation– He firmly believed that he had experienced extra

sensory perception…

Intuition in Decisions

• Situation:– The commander’s crew had arrived at a fire that

appeared to be a simple contained, kitchen fire.– The fire however was not responding to the direct

water spray from the living room– He also noted that the fire was much hotter than

expected– His “sixth sense” then kicked in– He pulled his crew completely out of the house

Intuition in Decisions

• Soon after they left the house the living room floor collapsed…

Intuition in Decisions

• Klein then asked him why he made the decision to pull the crew out– He was surprised that the water had no effect on

a seemingly small fire– He was puzzled at how hot the fire was– He thought it seemed odd at how quiet the fire

was from the living room

Intuition in Decisions

• His explanation was summarized by Klein:–He pattern he saw did not fit– The situation violated his expectations– Frankly, he wasn’t sure what was going on

Intuition in Decisions

• Overall, our experiences provide us with an expected set of patterns.– Intuition is fundamentally a pattern recognition

process• We use our expectations of these patterns to

match with a given situation• At times we cannot always verbalize what is

wrong when these patterns don’t match, but we innately know that the pattern doesn’t match.

Intuition in Decisions

• In follow-up studies Klein studied other professions including:– Military commanders– Pilots– Nurses

• He found that intuition played a powerful role in how experts in all fields “sized up" a situation and made decisions.

Intuition in Decisions

• Intuition is fundamentally a pattern recognition process– The patterns are formed from past experience– The process occurs very quickly– Unlike other decision-making processes we don’t

think through a series of alternatives

Intuition in Decisions

• Intuition gradually develops as someone gains a deep expertise in a specific field

• More situations lead to an increased ability to recognize and match patterns

• The thought is that while we are not always aware of it our mind is always searching for patterns for all situations that we encounter

• We use pattern recognition to spot problems and quickly guide us to solutions

Intuition and RRT’s

• Klein interviewed many nurses and physicians in his study of intuition– He realized that these professionals frequently

use intuition to make decisions– The patterns we look for are those assembled

from:• Vital signs, laboratory data, symptoms, physical

findings, and in obstetrics electronic fetal monitoring

Intuition and RRT’s

• There was a clear distinction between novices and experts and their ability to match patterns

• He often found that with experience nurses and physicians often sensed something wasn’t right before the data became clear

• How can we use this to improve patient care?

Intuition and RRTs

• Studies in England in the late ‘90s showed that in the hours before a patient had a cardiac arrest or other serious problems there were subtle signs of deterioration

• Efforts were made to find ways of detecting these changes more proactively

• Their interviews of many nurses after critical events occurred

Intuition and RRTs

• Discussions with nurses often lead to the realization that these nurses knew something wasn’t right and they had “a feeling” that things were turning for the worse

• This led to the development of rapid response teams

Intuition and RRTs

• Rapid response teams are mean to lead to an evaluation of the patient prior to them reaching a critical situation

• This is distinctly different than code teams which are called after a critical situation is reached– This distinction is critical!!

Intuition and RRTs

• The 100,000 Lives Campaign is a nationwide initiative launched by the Institute for Healthcare Improvement (IHI) to significantly reduce morbidity and mortality in American health care.

• Deploy Rapid Response Teams…at the first sign of patient decline

Intuition and RRTs

• Based on research showing that patients often exhibit signs and symptoms of increasing instability for several hours prior to a cardiac arrest — changes in breathing, heart rate, or mental status, for example — the idea is to rescue patients early in their decline before a crisis occurs.

Intuition and RRTs

• The Rapid Response Team intervenes upstream from a potential code situation, relying on bedside nurses who are highly sensitive to signs that a patient’s condition is deteriorating, and empowered to call others into action.

• Intuition is fundamentally a pattern recognition process– The patterns are formed

from past experience– The process occurs very

quickly– Unlike other decision-

making processes we don’t think through a series of alternatives

Intuition and RRTs

• Technical skills:• Adult advanced cardiac life support certification• Pediatric advanced life support certification• Critical care experience• Critical thinking • Assessment and diagnostic abilities• Ability to communicate concisely• Ability to recognize when they are unable to meet

the patient's needs

Intuition and RRTs

– The attitude of the team members toward the bedside staff, patient and families has a direct link to the overall success of the rapid response team program.

– It is imperative for the responders to keep in mind that "all rapid response team calls are warranted."

– If the bedside staff member does not feel respected and appreciated, or is intimidated by the responding staff, he/she may be reluctant to call the rapid response team in the future.

Rapid Response Team. Third Edition/May 2009

RRTs- other benefits

• Experts and novices at bedside together• People tend take the opportunity to

share their intuition with others• Through discussion of the case,

experts can help develop the intuition of novices

RRTs- other benefits

• Bedside patient discussions with the entire team present allows a level of teaching that cannot be accomplished in a classroom

Passing on of Wisdom

• The definition of apprenticeship• Socrates-the Socratic method– a form of inquiry and debate between individuals

with opposing viewpoints based on asking and answering questions to stimulate critical thinking and to illuminate ideas

– It is a dialectical method, often involving an oppositional discussion in which the defense of one point of view is pitted against the defense of another

Passing on of Wisdom

Thinking out loud–A key practice to use at bedside• Literally, talking through a thought

process• Not to be confused with second guessing

yourself• Explanations must be reassuring

Passing on of Wisdom

Thinking out loud–I’m doing this for the patient because…–I’m looking at this data because…–I’m concerned about this patient

because…–Why does this change in vital signs

concern me…

Passing on of Wisdom

• Thinking out loud–Using this process experts can share

how they develop intuition–Thought processes going on in the

mind of an expert–An optimal form of mentoring

Passing on of Wisdom

• Mentoring–Mentoring is ultimately how intuition is

optimally shared and developed– It requires• Astute observation by the mentor and the

student• Astute listening by the inexperienced• Empathy by the mentor• Excellent communication skills by the mentor

Passing on of Wisdom

• Pitfalls of using intuition– Misuse of analogy

• He picked the wrong analogy– Can make the wrong match to the situation

• Picked the wrong pattern– Overly complex situation

• Complexity of the situation can obscure pattern recognition• “Too much noise” Too many patterns or can’t see the most

important pattern• Outdated mental models- New data causes out dating of

information. Keeping up with new information

Passing on of Wisdom

Pitfalls of Mentoring•People need to understand your rationale and your intent in order to apply knowledge themselves•Communicate your intuition, get feedback•Ensure alignment- – Make sure what you want them to do and what

they think you want them to do are the same

Passing on of Wisdom

• Five steps:1) Here is what I think is going on2) Here is what I think we should do3) This is why/my rationale4) Here is what we need to watch for5) Tell me what you think• Tell what you understand of what I said• Are there any issues with my thinking?

Conclusion

• There is a link between intuitive thinking, the theory behind rapid response teams and how we can mentor less experienced members of our team

• Optimal thought processes and teaching are best done using a combination of intuition and analytical thinking

Bibliography

• Roberto, MA. The Art of Critical Decision Making. Chantilly, VA: The Teaching Company, 2009.

• Client, G. Sources of power: How People Make Decisions. Cambridge MA: MIT Press, 1999.

• Gladwell, M. Blink: The Power of Thinking Without Thinking. 2005.

• Healthcare Protocol: Rapid Response Team. Institute for Healthcare Clinical Improvement. Third ed., May 2009

• Institute for Healthcare Improvement. Rapid response information. Online