CLINICAL DECISION MAKING - 2 - Veterinary Practice
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SUSAN McKAY continues the series on the process of making clinical decisions in practice, with a look at ‘bias’ and analysis of risk, both real and perceived


Like most individuals, veterinarians have different perceptions of, and motivations for, decision making. No matter how logical clinicians think they are, they are still likely to have some degree of bias that could affect the quality of their decisions.

A study involving vets assessing metritis found that not only did their scores lack consistency within and between observers (variation) but also that vets made their decisions at three different levels of focus (cow, farm, population).

Treatment choices can also be affected by bias. One study found that doctors may prefer one treatment over another objectively similar one, select a sub-optimal treatment, or maintain an unsuccessful treatment beyond the point when they should choose an alternative course.

The same study suggested that there is some evidence that the adoption of an evidence-based medicine approach or the incorporation of formal analytical tools to make decisions can improve the quality of doctors’ reasoning.

Risk analysis

Of course, one of the most frightening things about making decisions, is that there is generally some degree of associated risk. This may be because there has been some uncertainty during the decision-making process (not all of the facts were known or available), because a number of credible alternative solutions existed, or the process was influenced by subjective views, bias or ambiguity.

Risk analysis includes risk assessment, risk perception and risk management.

Risk assessment addresses the probability that a likely sequence of events will occur. Some people rely on the opinion of an expert to come to that conclusion, others look at the consensus of opinion by a panel of experts.

In insurance, probability curves can be mapped, looking at the likelihood of events occurring and the likely losses that could be anticipated as a result. Linking probability and outcomes can be useful in a more practical sense too, by helping clinicians frame their dialogue with clients. In some situations there may be a low to medium probability that an event could occur (e.g. risk of side effects of a
medicine), but if it did the consequences would be significant (organ failure or death). In this scenario, it may be that clients would opt for the lowest probability of side effects, even if this meant paying more for a medicine, or choosing one that was more difficult to administer.

Perceived risk

Risk perception also comes into play here. Studies have found that when people had little knowledge about a hazard and also dreaded the consequences of that hazard, it was perceived as being most risky and some “hazards” gain a stigma that is not borne out by the scientific evidence.

It is very easy for the scientific community to belittle these perceptions because they are not based on fact. Certainly, in situations where compliance matters, the public’s perception of the risks associated with certain treatments has to be carefully considered.

What pet owners read on the internet is likely to have an impact. “Google” terms like “NSAID risks in dogs” and it immediately becomes obvious that the “information” pet owners use to make their decisions may alter their perceptions of the value of some treatments.

On the plus side, a US report found that clients rate the internet fourth in trustworthiness, with vets by far the most trusted source of pet health information.

Another study found that when clients visited a healthcare facility website, they required less time to process information and make medical decisions. Perhaps, then, there is scope to not only provide information on practice websites but also to give the level of information that will help clients to make better decisions, in everything from when to seek help, to preferred treatment options.

Risk management involves tackling both the actual risk and the perception of risk. Crisis prevention could involve developing contingency plans, which can be built into, or sit alongside, practical protocols.

There may be possibilities to use existing resources differently or use new resources, such as new treatments or equipment, to mitigate risk.

If the decision-making process in use has been robust, logical and allowed all the alternatives to be properly evaluated, then that in itself will ensure that clinicians are sensitive to the presence of risk and that the final decision is made with reference to that risk.

There are opportunities to increase confidence in the decisions we make.

References and further reading

4. Lastein, D. B., Vaarst, M. and Enevoldsen, C. (2009) Veterinary decision making in relation to metritis – a qualitative approach to understand the background for variation and bias in veterinary medical records. Acta Vet Scand 51(1): 36.
5. Bornstein, B. H. and Emler, A. C. (2001) Rationality in medical decision making: a review of the literature on doctors’ decision-making biases. Journal of Evaluation in Clinical Practice 7 (2): 97-107. 6. Risk Analysis, Kunreuther H (accepted for publication in the Social Science Encyclopedia). 7. Slovic, P. (1987) The Perception of Risk. Science 236 (4,799): 280-285. 8. Kogan et al (2010) The Internet and Pet Health Information: perceptions and behaviours of pet owners and veterinarians. The Internet Journal of Veterinary Medicine 8 (1). 9. Fergusson, T. (2000) Online patient-helpers and physicians working together: a new partnership for high quality health care. BMJ 321: 1,129-1.132. 10. Mullan, S. and Main, D. (2001) Principles of ethical decision-making in veterinary practice. In Practice 23: 394-401. 11. Markkula Centre for Applied Ethics, A Framework for Thinking Ethically.… on/framework.html.

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