I have been interested in the recent discussion of rapid clinical decisions
being made by experts, influenced by first impressions, heuristics, and so
on. My interest in similar processes in patient decision-making has led me
to consider what decision-making theories and methods can offer.
Experimental studies suggest ample evidence of deviance from the reasoned,
deliberate, analytic mode of cognitive processing advocated by classical
approaches to decision making. Theories of "naturalistic decision making"
(NDM) have emerged which emphasise more automatic, intuitive processing
(e.g., rules of thumb, gut instincts) which have been frequently found to
be cognitively efficient and adaptive in a wide range of "real world"
contexts (eg, judges's sentencing, fire-fighting, divorce, genetic
testing). Postings to this list suggest their prominence in clinical
decision-making.
How to investigate processes of decision-making which are rapid, automatic,
and likely to be less consciously available is of course fraught with
problems. As Roy Poses suggests, verbal reports in which participants
analyse, explain and interpret their own processes or behaviour have been
found to be less valid than direct reporting of thoughts. Some methods are
emerging which researchers such as Toby Lipman might find useful. These
include methods such as "think aloud" techniques which involve participants
reporting all the thoughts that arise while performing a decision task or
as soon afterwards as possible. This is not always practical in clinical
consultations, and one study of a general practice consultation involved
patients being asked to "think aloud" as they listened to an audio-visual
tape of the consultation, stopping it at will. Similar approaches could
easily be adapted for clinicians. Approaches such as hypothetical,
scenario-based vignette studies may also be useful. One study has employed
think aloud techniques for participants immediately after hearing a brief
audiotape describing a simulated scenario. Other "processs tracing"
techniques employed include information acquisition tasks such as
computer-based searching where the decision-maker's clicking of information
sought is tracked and analysed.
A better understanding of the processes which underlie clinical decisions
will assist in identifying those which are efficient and effective and
those not. For those interested in these issues, Susan Michie and I have a
paper titled "Processes of patient decision making: theoretical and
methodological issues", due out this month in Psychology and Health's
special issue on emerging models and methods, Issue 15(2).
cheers
Marita Broadstock
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Marita Broadstock
Research Fellow
NZHTA
New Zealand Health Technology Assessment
Department of Public Health & General Practice
Christchurch School of Medicine
University of Otago
PO Box 4345
Christchurch
NEW ZEALAND
Tel: ++ 0064 (3) 364 1480
Fax: ++ 0064 (3) 364 1152
Web Site: http:/nzhta.chmeds.ac.nz/
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