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The classical approach to decision making gives the picture of a relatively simple
linear sequence of stages together with a rational and systematic process of thinking
followed by the implementation action. In practice, the process is more complex
and variable. It is a human process. The cycles of phases are more complex than
a simple sequence suggests. Each phase in a particular decision is itself a complex
decision making process with the possibility of much recycling back, and wheels
within wheels. The classical decision process must adapt itself to the actual situation
at hand.
In the real world, decision processes cover structured, semi-structured and unstructured
situations. For some medical problems the situation can be repetitive, routine and
well understood. Then the problem can be precisely stated and definitive protocols
and standard operating procedures for handling the situation are available. To the
extent that information is generally available and direct practical experience can
be routinely included in a systematic decision process, then decisions can be routinely
made. For other medical problems the situation can be more complex. These decisions
involve more intangible and judgemental factors and risks. In the final analysis
these elements of judgement are essential as they can have a major impact on the
success of the decision.
In the real world, the time factor is a primary determinant in decision making.
A decision must be made within a finite time frame; most decisions are usually made
against a deadline. Emergency situations require immediate decisions based on experience
and a general capacity for intelligent adaptive problem orientated action.
Many decisions have to be based, to some degree, on incomplete knowledge either
because information is not available or it would cost too much in time and money
to get it. It is important never to jump to conclusions before assembling the facts.
On the other hand, if a decision maker works for perfection and awaits the completion
of an exhaustive data gathering exercise before reaching a decision, then the only
analysis is paralysis and the main response is insecurity.
There can be an erroneous assumption that more data will provide better decisions;
this is not necessarily the case. Emphasis on facts approach must be seen in context.
In medical decision making, the doctrine of materiality is important. Sometimes
there is an emphasis on facts and quantification as a way of demonstrating the perception
of a rigorous examination of the problem. However, too much of an emphasis on data
gathering can become an obstacle in decision making as it may bring unnecessary
complexity.
To cope with the real life complexity of many problem situations, a structural hierarchy
in decision making is generally established, whereby classes of decision are related
to ascending management levels. To the extent that personal judgement is required,
then factors like academic qualification, training, breadth and depth of experience
in the subject area, and professional accreditation provide a sound basis for effective
decision making. People with the required technical expertise and with effective
personal functional competence are allowed to get on with the job.
The routine use of personal professional judgement in decision making can mean a
degree of departure from the rational decision process. Typically people develop
and then use unconscious routines, systematic rules of thumb or shortcuts to cope
with the complexity and uncertainty inherent in difficult decisions. Psychologists
have learned that human beings rely on mental shortcuts to make complex decisions.
These routines, known as heuristics, serve us well in most situations. Some steps
in the decision process may then be performed implicitly, even randomly rather than
explicitly and systematically. Yet, like most heuristics, they are not foolproof.
Errors in the exercise of such judgement can occur.
Cognitive psychology, in its exploration of how irrational decisions are sometimes
made, demonstrates that the human factor in decision making can introduce several
sources of error and bias. We all like to believe that we make decisions rationally
and objectively. But the fact is, we all carry biases, and those biases influence
the choices we make. At every stage of the decision-making process, misperceptions,
biases, and other irrational anomalies in thinking can influence the choices made.
While these anomalies in thinking can work in isolation from each other they can
also work together to amplify each other, giving rise to serious distortion in rational
decision making. Highly complex and important decisions are the most prone to distortion
because they tend to involve the most assumptions, the most estimates, and the most
inputs from the most people.
The way a problem is framed can profoundly influence the choices made. A framing
trap occurs when the problem is misstated thus undermining the entire decision-making
process.
There are anchoring errors where the first symptoms anchor the thinking process
on an incorrect diagnosis of the problem. It gives disproportionate weight to the
first information received. Initial impressions, estimates, or data anchor subsequent
thoughts and judgments
Another type of judgement error can occur when a recent or dramatic experience is
assumed to correspond to a new problem situation; the availability trap. Personal
emotions can mean that personal feelings colour the thinking process; affective
errors where emotions can trump rationality.
A risk with specialisation in the medical profession and with professional expertise
in decision making is a bias to seek out information that supports an existing instinct
or point of view while avoiding information that contradicts it. This confirming-evidence
trap leads to seeking out information supporting a personal preference and to discount
opposing information.
People frequently must determine whether an event is the product of a particular
process or is a member of a certain category of events. When the event is similar
to the category, people judge the likelihood that the event is a member of that
category as high e.g. a defendant's nervous demeanour evinces a guilty conscience,
and when the event is not similar to the category, people judge the likelihood that
the event is a member of that category as low. Psychologists refer to this decision-making
strategy as the representativeness heuristic. It can be a wonderfully accurate rule
of thumb, but problems can arise because people tend to rely on the representativeness
heuristic to the exclusion of other information relevant to categorical judgments.
Medical treatment decisions generally involve a treatment plan carried out over
a period of time. On occasion it may happen that the expected patient progress is
not satisfactory and the initial decision may require reassessment. Increasing commitment
to a failing course of action may simply be a way to protect an earlier decision;
in effect a deep-seated bias to make continuing choices in a way that justifies
past choices. Frequently, people are unwilling, consciously or not, to admit to
an error of judgement.
Another set of traps that can have significant impact on decision making relates
to the decision makers attitude to risk. Medical decision making nearly always involves
choice between alternative solutions and always involves risk as it is concerned
with estimates of future. The pessimistic personality tends to be overcautious when
making decision under uncertainty; the tendency is to be on the safe side what ever
happens. Too much prudence can sometimes be as dangerous as too little. At the other
end of the scale the overconfidence trap leads to overconfidence in one’s own ability.
Over confidence can lead to a rush to judgement without thinking things through.
That in turn can lead to bad decisions.
Allegations of errors of judgement in medical diagnosis and treatment decisions
form a significant part of medical malpractice situations.
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