First Principles of Shared Clinical Decision Making

 

First Principles of Shared Clinical Decision Making

For we do not think that we know a thing until we are acquainted with its primary conditions or first principles, and have carried out analysis as far as its simplest elements. ~ Aristotle

In the October 7, 2022 post, I referred to mental models, which can be thought of as pathways for good thinking. One of the oldest mental models, first proposed by Aristotle, is called First Principles. 

James Clear has written a terrific blog post describing the First Principles mental model. [1] He explains that it involves reducing a process to the basic functions needed to accomplish a specific purpose.  First Principles reasoning can be used to both gain a deeper understanding of a current process and as a mechanism to develop new, innovative ways to accomplish something. 

Clear cites the Gutenberg printing press as a good example of innovation based on First Principles reasoning. Gutenberg’s innovation was combining screw press technology, then being used to make wine, with moveable type, then being used for printing. Both were well-developed technologies in common use that had never before been combined. (The story of Gutenberg and the printing press is fascinating. Here is a brief overview.)

The key to First Principles thinking is to remember that form and function are not the same.

The natural tendency is to seek improvements by tweaking one or more elements of an existing format.  Reasoning by First Principles involves changing the focus from the current format of an object or process to its function: what it is supposed to do.  As illustrated by the Gutenberg example, innovations frequently occur when new components are introduced that are not part of the current form. Clear describes this distinction as follows:

Old conventions and previous forms are often accepted without question and, once accepted, they set a boundary around creativity. This difference is one of the key distinctions between continuous improvement and First Principles thinking. Continuous improvement tends to occur within the boundary set by the original vision. By comparison, First Principles thinking requires you to abandon your allegiance to previous forms and put the function front and center. What are you trying to accomplish? What is the functional outcome you are looking to achieve?

If you are interested in reading more about First Principles reasoning, I encourage you to read Clear’s original post. [1] The Farnum Street Blog also has information about this and a host of other mental models. [2]

Musings

As I learned more about the First Principles model, I began to wonder how it could be used to address the current difficulties incorporating shared decision making into clinical practice. Here’s my current thinking:

The objectives of shared decision making are to make a good decision that accurately reflects a patient’s preferences and priorities.

If so, it follows that a number of specific functions need to be accomplished:

Needed to make a good decision:

  • Ready access to an accurate, trustworthy summary of current evidence in a format designed to support clinical decisions. 

  • Inclusion of all important decision-related considerations from both the provider and patient perspectives.

  • Inclusion of a full set of options. 

  • A mechanism for coping with decision-related uncertainties.

  • A sound reasoning process designed to minimize the adverse effects of cognitive biases.

Needed to accurately reflect patient preferences and priorities:

  • A simple but effective procedure to identify important considerations from the patient’s point of view.

  • A simple but effective procedure to assess patient decision priorities.

  • A simple but effective procedure to help patients compare decision options.

Needed to make a shared clinical decision

  • A mechanism allowing patients and clinicians to understand and discuss each other’s  decision related preferences and priorities.

  • A procedure that is accepted by clinicians as feasible, worthwhile, and trustworthy. 

  • A procedure that is accepted by patients as worthwhile and trustworthy. 

  • A mechanism for recording the decision making process and documenting it in the medical record.

Even this preliminary list demonstrates that shared decision making is complex. It seems to me that most current efforts to incorporate shared decision making into clinical practice - like the 3 talk model and others discussed in recent posts - are trying to accomplish these functions by tweaking traditional formats for clinician-patient interactions. The list of necessary functions indicates that this approach is unlikely to succeed. There is just too much to be done that has not been part of the usual procedure.

If accurate, this First Principles analysis suggests that the standard clinical interaction needs to be expanded. Additions are needed that will enable clinicians and patients to perform all of the functions needed to successfully make high quality, shared clinical care decisions. Tweaking the conventional format alone will not work. 

Note

Please feel free to comment on this analysis and my musings. I am interested in using this newsletter as a platform for expanded and enhanced discussions about how to make good medical decisions that will improve the quality of healthcare patients receive. 

References

1. James Clear, First Principles: Elon Musk on the Power of Thinking for Yourself. https://jamesclear.com/first-principles

2. Farnum Street Blog, First Principles: The Building Blocks of True Knowledge,   https://fs.blog/2018/04/first-principles/

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