Decisions Decisions by David Macnair

Do you make decisions at work? I’ve asked this question a lot. The reply is usually the same. A hesitant nod of the head, perhaps. Or a lop-sided shrug with that expression that says “Dunno. Do I?” Despite making decisions every minute of every day, we most often don’t notice we are doing it. Which means we can make it better. We can ask, “Do you make good decisions?”

In fact, we human beings are decision making machines. We might make life or death decisions about patient care. But it is mostly humdrum day to day decisions. When am I going to get up for work? Which buzzer am I going to answer first? Shall I go for a pee before I do the next task? Should I push or pull that door?

First let us look at how we make decisions. These four categories cover most of the ways we make decisions in a clinical setting. They are:

• Option appraisal
• Rule based
• Novel solution
• Recognition primed

Let’s take a look at each of these in some more detail.

1: an example of a poor decision

Option Appraisal

Do you recognise this heroic looking guy?

2: The Thinker

Option appraisal is the classical approach to decision making. One sits hunched with chin in hand and thinks of all of the possible options for a given situation. Each of these options is weighed up individually, looking to see the pros and cons. When finally a single best option is clear, a decision is taken. The major benefit of this approach is that it is the most likely to produce a good decision for the given situation. It is also easier to justify your decision later. Unfortunately, there are drawbacks. It requires mental effort and time. It requires a systematic approach. If you don’t know all the possible options, you could miss the right one! It requires some background knowledge. A medical example of option appraisal is writing a differential diagnosis. This is a list of possible illnesses (ie options) that a patient with particular symptoms might have. Writing a differential diagnosis forces you to consider diagnoses other than just the one you wrote first.

But is this how we usually make decisions? No! Of course not. If every decision we made required this process, we would become paralysed; unable to get anything done for thinking about it.

Rule based

3: Guidelines say we have to have 5 nurses on the ward. This is Sandra, also known as Claire, Fiona, Jade and Emma.

This one is easy. Think of a guideline, any guideline. This can be thought of as a “rule” on which to base your decision making. A good example is basic life support. You know the drill (or you should- it’s mandatory!) There are benefits to having a rule. It’s fast. It standardises the decisions. If everyone knows the same guideline, then you can work together as a team. You don’t need to sit down and think- someone else has done the thinking for you.

There are buts. You know there is a guideline for cardiac arrest. What about the one for anaphylaxis? Or escalation of the deteriorating patient? Or the guideline for pre-eclampsia, or diabetes, or needle stick injuries, etcetera etcetera… The trouble is, you need to know there is a rule to follow it. You also need to be able to find that rule. Have you tried looking for a guideline on hippo? It’s not always easy.

Other drawbacks? It doesn’t allow you to think “out of the box”. Guidelines can sometimes be too rigid. Some guidelines are complex, and so easily misunderstood. In these cases, it might be most appropriate to have a copy of the rule to hand as you are carrying out the task. Also you can apply the wrong rule if you have picked up the cues wrong. It wouldn’t be the first time that a patient had been “defibrillated” because an ECG lead was hanging off…

Novel Solutions

While we are on the topic of “thinking out of the box”, we can take a quick look at this one. Novel solutions are things we think up on the fly when there isn’t a solution readily available. An example would be using a tongue depressor to splint a baby’s arm. These solutions are occasionally a necessity, but most likely to result in unintended outcomes.

4: The BBC substitutes sarcasm with inverted commas as the lowest form of wit

Recognition Primed

Which brings us last, but not least, on to recognition primed decision making. It’s that pattern recognition thing. You walk in to a room and immediately just know what’s wrong. This way of thinking was described first when firefighters were being observed. When asked afterwards how they came to a decision, they would say only one option would come to mind, not a whole list like in classical option appraisal. They would then run with that idea, assessing at intervals whether the decision was having the intended effect.

This is how most of us do it. We make a decision from one single best fit option. The major benefit is that it is fast, sometimes supernaturally so. It doesn’t require much mental effort, and so is resistant to stressful situations. However, it is more likely to be wrong than a good sit down and think. In other words, some of your most experienced team members are more likely to be wrong because their pattern recognition has short circuited their decision making process. Be aware of this.

Thinking biases

There are other factors that can affect how we make decisions. Our decision making may be entirely rational, but there are biases that creep in to trick us. Here are some examples:

• Confirmation bias. Take a diagnosis of bleeding for example. We tend to look for the symptoms and signs that confirm our diagnosis. We see the increased heart rate, the decreased blood pressure but ignore the wheezy chest that tells us the diagnosis not bleeding. This is a common failing when humans make decisions. Remedy? Take the symptoms that don’t fit seriously, and do not dismiss them.
• Premature closure. In a similar vein, if we make a diagnosis, we stop looking for another diagnosis. Again this is common, and can often lead to missed problems. Remedy? First, use forcing functions, like writing a list of possibilities rather than just one option. Second, continually review your decisions especially in the light of changes.
• Attribution bias. If something looks like a duck and quacks like a duck, we assume it’s a duck. So if someone looks and acts drunk, we assume he is drunk. Even if his symptoms are caused by a subdural haematoma. Remedy? Look for the facts to either corroborate or contradict your duck theory.
• Base rate neglect. If something looks like a duck and quacks like a duck, don’t assume it’s a Christmas Island Frigatebird. Oddly, sometimes we do ignore the most common things and decide to pick the least likely option. Remedy? Assume it’s a duck. No wait…

5: Not a duck

H.A.L.T .

Our decision making may not be rational. We are human beings and there is most often more than one set of values at play. Decisions are often made when we are Hungry, Angry, Late or Tired. Or indeed is there some other conflict? Do you dislike the person you are making a decision for? Do you disagree with a senior colleague? This happens all the time. A couple of months ago I saw a patient in the emergency room with a head injury. The long and short was that his conscious level was decreased and he needed transferred to Edinburgh. The options were I could take him, or he could go with a nurse transfer. But I’d already been working for 12 hours by this point; the transfer to Edinburgh always takes 5 hours, and it was arguable that he was well enough to go with a nurse rather than an anaesthetist. Ish.

So the decision was made to transfer with a nurse (sorry Sarah). But I second guessed myself and phoned a friend. After discussion, he said “Well, if it was me, I’d go…” So I sloped back to the emergency department to find the patient already out the door! Further decisions were punctuated by interesting vernacular; suffice to say, I ended up in the back of an ambulance after some less than elegant decision making.

What can we learn?

On reflection, there are several things we could learn from this. We need to be aware when we are making decisions. This allows us to think how we are making decisions- is it recognition primed? Is it option appraisal? We can think what aids there are to help us such as rules or guides. We must realise what barriers are in the way of our decision making. Things like hunger, anger, lateness or tiredness can all be dealt with to improve our decision making.

Any last tips? Often it helps to stand back and take time to weigh the options. A colleague can be a valuable resource. If a decision is not clear, talk to someone about it. Possibly most helpful of all, it is important to reflect after the fact. What decision did I make? Did it have the desired effect? Could I improve on it next time?

Do you make good decisions?

David Macnair is a Consultant Anaesthetist at NHS Dumfries and Galloway