CLINICAL DECISION MAKING - 1 - Veterinary Practice
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SUSAN McKAY introduces a new series on the process of making clinical decisions in practice, with the aim of ensuing that the ‘right’ decision is reached as often as possible

DECISIONS, decisions … we make a lot of them in general practice but do we always make the right ones?

As scientists, we all like to think we are logical, rational beings but in demanding situations the decisions we make are influenced by many things: time pressures, experience, higher stakes, ambiguity and uncertainty.

In those situations, the tendency is to fall back on our intuition, without really weighing up all the alternatives. Is decision making something we could be doing more effectively?

A matter of confidence

The process of decision making in clinical situations is receiving increasing attention. Few outcomes are predictable in medicine, so techniques tend to focus on addressing the concept of “uncertainty” in a more formal way.

The aim is to make “robust decisions”, using all available resources to evaluate the options to find the best possible choice that provides acceptable levels of satisfaction and risk. Formalising the process increases confidence that nothing is missed and the “right” decision is reached.

Intuitive decisions

We can all appreciate that there are times when the decisions we make are “time bound”. These decisions are made in the heat of the moment, often without any conscious recognition: e.g. treating the patient brought in after an RTA.

These may not be “bad” clinical decisions as they often use tacit knowledge. This is what we know at such a deep level that it is hard to verbalise or explain to others. It’s often something that people dub “experience” or something that they “just know”.

However, intuitive decisions can be flawed too: perhaps due to our prejudices, previous experiences (this worked the last time), short-term bias, over confidence (this worked the last time!) or flawed information (actually, now I come to think about it, this didn’t work the last time).

In the real world we perhaps have to accept that there will always be times that we rely on our intuition, as otherwise we would become paralysed by indecision but, equally, we should also be aware that there is scope to be more rigorous in our approach to making day to day clinical decisions.

Difficult decisions

Having too many choices can make for difficult decisions. In a clinical situation there are often multiple scenarios that can be played out.

Sometimes the decisions we make are in response to relatively simple problems but more often they are complex problems, which are often referred to as “messy”.

In business there are many of these so-called messy problems and theorists in organisational management have developed a variety of techniques that can be used to make decisions: grid analysis, force field analysis, decision trees, brainstorming and reverse brain storming, to name but a few.

In medical practice, Markov models have been suggested as a means to make clinical decisions. These are used when a decision involves risk that is continuous over time, when the timing of events is important, and when important events may happen more than once.

The technique uses what are essentially modified decision trees that allow for greater complexity. The patient is assumed to be in one of three states (usually well, ill or dead) and potential transitions from one state to the other are charted (obviously there is no way back from dead) and probabilities assigned.

For the average clinician in practice, Markov models might not always seem immediately practical, as they use statistical analysis, but the techniques can be used to look at survival rates, quality of life and health status.

Perhaps the most interesting aspect of this model is that it provides a means to formalise and structure decisions, in situations where medics and vets have formerly had to rely on their “best guess” or a “hunch”.

Approaches to decision making

So, what are the steps that need to be taken in good decision making?

  • Atmosphere – use the right tools, create the right environment, listen to stakeholders.
  • Options – develop as many possible alternatives as you can.
  • Testing – examine all the pros and cons for each alternative, view the options from different perspectives.
  • Choices – choose the best option.
  • Check – check you have made the right decision, if necessary by consulting with others.
  • Share and act – let everyone know the final decision and take action.

Various techniques can be employed at each stage: brainstorming may be appropriate when generating possible options, grid anaylsis may be useful when making a final choice.

There are many variables: should you consult with the whole team, taking more time but achieving better “buy-in” to the decision (for example, where decisions are being made about practice protocols) or just ask a trusted panel, or only experts/specialists?

Shared decision making

How often have you heard the “put yourself in my shoes” plea from clients: “What would you do if this were your pet?” Every clinician knows that this is a cry for help because the client doesn’t know what to do. In some respects this may be a reflection on the situation – clients are often put in the position of having to make a decision that perhaps they were not prepared for, or have inadequate knowledge to evaluate and in a time-sensitive situation. Such decisions are often highly subjective.

A recent survey found that pet owners believed that if their pet was diagnosed as suffering from a chronic painful illness, the word that would best describe their feelings was “devastated”. The rational clinician, knowing that pain can be managed, may find this hard to understand and it is often this emotional reaction that is hardest to gauge. Shared decision making is a more evolved approach to this dilemma.

The US-based Dartmouth Institute for Health Policy and Clinical Practice, describes the process this way, “A different model of the doctor-patient relationship is emerging in response to the rebellion against both paternalism and third-party intrusion into medical decision making. Shared decision making recognises that there are complex trade-offs in the choice of medical care.

“Shared decision making also addresses the ethical need to fully inform patients about the risks and benefits of treatments, as well as the need to ensure that patients’ values and preferences play a prominent role. Most patients willingly participate in shared decision making, even when decisions are complicated and difficult.”

Key to thinking about shared decision making is that clinicians should not make assumptions about what a client wants. This is often talked about in relation to the cost of treatment, but the implications are potentially much wider.

In many cases there are multiple treatment options, including the option not to treat. Preference-sensitive conditions – where there are two or more valid treatment options – involve choices based on the client (and patient’s) needs, desires and lifestyle. For shared decision making to work, the client needs to be given complete and balanced information on all viable options. In turn, the client communicates his or her values and the relative importance he or she places on benefits and risks.

In human patients this greater level of involvement means better compliance with treatment programmes and they often rate their health after treatment more highly.

  1. Medical Decision Making (1983) 3 (4) Markov Models in Medical Decision Making: A Practical Guide, Frank A. Sonnenberg, J. Robert Beck.
  2. decision_making.html.
  3. www.informedmedicaldecisions.o… (multiple references on shared decision making between human patients and physicians).

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