Medical Decision Making Musings

 What medical decision makers can learn from Major League Baseball. Shared decision making is ideal in theory, but in reality, it is fraught with risks resulting from cognitive biases and undue influence of even the best-intentioned physicians and family members. Efforts should be made to minimize these concerns and to help patients to make decisions that their future selves are least likely to regret. [1] Next week marks the end of the baseball regular season in the United States. Therefore I thought it would be timely to speculate what the world of medical decision making could learn from Major League Baseball. In 2011, Daniel Kahneman published the highly acclaimed book: Thinking Fast and Slow . [2] It rapidly became a New York Times bestseller, was widely reviewed in the professional and general literature, and won several awards including the National Academy of Sciences Best Book Award. The book summarizes Kahneman’s research findings about factors that affect how people ma...

  Stocks, flows and time lag in systems: Implications for shared decision making research System dynamics (SD) is an approach to understanding the nonlinear behaviour of complex systems over time using stocks, flows, internal feedback loops, table functions and time delays. [1] One of the basic lessons of looking at a complex system through the lens of system dynamics is that it takes time, sometimes a surprisingly long time, to alter a component of a system that has been functioning in the same fashion for a while. In the language of system dynamics, this cumulative experience of one type of behavior is called a stock. Even with a steady inflow of new behaviors, unless there is a correspondingly large outflow of old ones, the overall behavior of the system will change only slowly. A classic example is what happens in a bathtub that is full. Now start adding new water from a faucet and open the drain. The inflow is new water from the faucet, the outflow is the water ...

   Incorporating shared decision making in routine clinical practice: The missing link? In 2017, Sarina Schrager and colleagues published a paper describing how shared decision making (SDM) for cancer screening decisions can be implemented in primary care settings. [1] It is freely available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697707/ As of Sept 22, 2022 it has been cited 26 times according to Google Scholar . Schrager and her colleagues explain that learning how to incorporate SDM into practice is important because it is a framework for providing the type of high quality care advocated in the Intitute of Medicine’s Crossing the Quality Chasm report that is “ …respectful of and responsive to individual patient preferences, needs and values” . [2] They then describe three SDM models: the AHRQ SHARE method, the 5 A’s method described by the US Preventive Services Task Force, and the IAIS (Invite, Acknowlege, Instruct, Summarize) model. They conclude that...

  In the  September 13, 2022 newsletter , I reviewed an article suggesting that the term shared decision making itself could be contributing to the difficulties implementing it in clinical practice. The proposed solution was to rebrand shared decision making as “contextualizing decisions”. Today, I’d like to expand on this idea further by posing the question whether shared decision making should be considered separate from regular clinical decision making.  This question is addressed in David Eddy’s 1990 article  Anatomy of a Decision.  [1] His focus is improving the quality of healthcare which he defines as follows:  “THE QUALITY of medical care is determined by two main factors: the quality of the decisions that determine what actions are taken and the quality with which those actions are executed - what to do and how to do it. If the wrong actions are chosen, no matter how skillfully they are executed, the quality of care will suffer. Similarly, if the c...