Overview of Medical Decision
Making
HINF 371 - Medical Methodologies
Session 2
Session Objectives
To understand the stages of rational
decision making in medicine
 To understand the information needs
at each stage

Reading



Mar CD, Doust J, Glasziou (2006) Chapter 1: Principles of
clinical problem solving, in Clinical Thinking: Evidence,
Communication and Decision-Making, Blackwell Publishing
and BMJ Books, USA
Eddy D (1990) Anatomy of a Decision, JAMA, No.263,
pp.441-443
Chapman G B and Sonnenberg F A (2000) Chapter 1:
Introduction, in Chapman G B and Sonnenberg F A (eds)
Decision Making In Health Care: Theory, Psychology and
Applications, Cambridge University Press, USA, pages:11-19
Decision Making Process
Experience the Situation in a changing Context
Define problem and Reframe it
More data
No
Yes
Clarify/Reframe
Expectancies
Anomaly
Relevant Clues
Decide
Plausible Goals
and Objectives
No
Typical Actions
Implement
Will it
work?
Yes, but
Modify
Next Episode
Experience the Situation in a changing Context
Decision Making
Is
situation
typical?
Diagnose
Decision Making Steps
Sorting out
the problem
Action
Integration
P
Problem
Define the problem. How does the problem affect
health?
R
Reframe the
Problem
From multiple perspectives: think everyone’s, now and
in the future
O
Objectives
What is the best outcome we could achieve? Provider’s
objectives, Patient’s objectives
A
Alternatives
List alternatives (treat, wait and see, or test)
C
Judgments
Consequences
Imagine outcome
of each alternative
Analysis
T
Trade-offs
Review benefits and harms of each alternative
IV
Values
What are the patient values and preferences? What are
the practitioner’s values and preferences?
E
Exploration
Preferences
1. Benefits of a practice must be compared with the
Judgments
harms
2. Health outcomes must be compared to costs
3. Compare benefits and costs of each alternative
Policy
Evidence
But can we do all in
minutes?

Novice




Competent




Rigid adherence to taught rules or plans
Little situational perception
No discretionary judgement
Is able to cope with “crowdness” and pressure
Sees actions partly in terms of long-term goals or a wider
conceptual framework
Follows standardized and routinized procedures
Expert



No longer relies explicitly on rules, guidelines and
maxims
Has an intuitive grasp of situations based on deep, tacit
understanding
Uses analytic approaches only in novel situations or when
problems occur
Model of decision making for
experts
Match each situation with a prototype
 Use their experience to create
prototypes

What can go wrong?

Misperception of evidence









Important outcomes might be ignored
Extraneous outcomes might be included
Evidence might be incomplete
Existing evidence might be overlooked
Evidence might be misinterpreted
Incorrect reasoning
Personal experiences might be given undue weight
Wishful thinking takes precedence
Misperception of the patients values on the outcomes





Patient misunderstand the outcomes
Measure of the effect could be misleading
Presentation of outcomes might be misleading (e.g. ARR RRR)
No attention paid to patients values
Provider project their own values and preferences to the patient
Avoidance of pitfalls



Decisions must be based on outcomes that
are important to patients
The effects of a practice on outcomes
should be estimated accurately.
Preferences assigned to the outcomes of
an intervention should reflect as accurately
as possible the preferences of the people
who receive the outcomes - patients
Extraneous Outcomes








Type of evidence (no RCTs therefore can
use case results)
Degree of certainty (significance)
Common sense
Commonness of disease
Seriousness of the outcome
The need to do something
Novelty and technical appeal of an
intervention
Pressure from patients, family, press,
courts, paperwork, financial interests
How is this evidence
prepared
Discussion – How can we
support this process?
Sorting out
the problem
Action
Integration
P
Problem
Define the problem. How does the problem affect
health?
R
Reframe the
Problem
From multiple perspectives: think everyone’s, now and
in the future
O
Objectives
What is the best outcome we could achieve? Provider’s
objectives, Patient’s objectives
A
Alternatives
List alternatives (treat, wait and see, or test)
C
Consequences
Imagine outcome of each alternative
T
Trade-offs
Review benefits and harms of each alternative
IV
Values
What are the patient values and preferences? What are
the practitioner’s values and preferences?
E
Exploration
1. Benefits of a practice must be compared with the
harms
2. Health outcomes must be compared to costs
3. Compare benefits and costs of each alternative