The anatomy and pathology of clinical decision making.

 

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 correct actions are chosen but the execution is flawed, the quality of care will suffer.” 

In other words: 

Quality of care = Decision Quality (Knowing what to do) + Quality of care delivery (Knowing how to do it properly)

Eddy notes that up until 1990, much more attention had been paid to the quality of care delivery than decision quality.  A major goal of the article is to point out that decision quality is a major variable affecting the quality of healthcare:

“The importance of ensuring the quality of execution is well understood. In contrast, the medical profession has done much less to develop and evaluate its decision-making processes. If decisions are considered the command post and actions are considered the troops in the field, we have spent much more energy training and equipping the troops than providing intelligence and decision support systems to the commanders.”

As far as I can tell, this situation has not changed much in the past 30 years.

Eddy then uses a standard clinical format to describe clinical decision making starting with the anatomy of a clinical decision, then describing decision making pathology, and finally treatment. 

He depicts the anatomy of clinical decisions as follows: 

“In general, the goal of a decision regarding a health practice is to choose the action that is most likely to deliver the outcomes that patients find desirable. This identifies the two main steps of a decision … First, the outcomes of the alternative practices must be estimated; then, the desirability of the outcomes of each option must be compared.”

Eddy then relates that decision pathology results if the possible decision outcomes are incorrectly estimated or if patient preferences are not adequately ascertained and taken into account: 

“Misperceptions of patients' preferences can also occur. Patients might misunderstand an outcome, the measure of the effect might be misleading, the outcomes can be presented in different ways that lead to different conclusions, the patient might not be consulted at all, or physicians might project their own preferences onto their patients.”

Eddy then goes to describe three principles of treatment to avoid poor quality clinical decisions:

“First, decisions should be based on outcomes that are important to patients. These are the ‘health outcomes’ that patients can experience and care about.”

“Second, the effects of a practice on outcomes should be estimated as accurately as possible, given the available evidence … and the information should be presented in a form that is meaningful and intelligible to patients.”

“The third principle is that the preferences assigned to the outcomes of an intervention should reflect as accurately as possible the preferences of the people who will receive the outcomes—that is, patients. Patients should be encouraged to participate in the decisions to the extent they want. If a patient chooses to delegate the decision, the person chosen to act as the agent must understand that the values he or she expresses will be projected onto patients.”

MUSINGS

Clearly, in Eddy’s view, shared decision making should not be considered separate from regular clinical decision making. Rather, it is an integral part of it. If so, perhaps there is no need to propose that clinicians and health care systems adopt a new way of doing business. They just need to focus making good decisions. I think this idea has a lot of merit. 

This is not a highly cited reference with regard to shared clinical decision making but it speaks to the topic directly. (In fact, I haven’t been able to find any references to it. If anyone knows of any, please let me know.) I think it should be added to the list of seminal articles about the importance of honoring patient preferences and values in decisions about their care. 

The other striking feature of Eddy’s article is that he treats decision making in a format familiar to clinicians. In my experience most articles discussing shared decision making do not. This raises the possibility that another problem implementing shared decision making is that the current literature is written in a format clinicians are not used to and non-clinical journals. Adopting clinical terms and formats in information aimed at clinicians could facilitate implementation efforts. 

References

1. Eddy, David. Anatomy of a Decision | JAMA | JAMA Network. JAMA. 1990;263(3):441–3.