The OODA loop and clinical decision making


The OODA loop and clinical decision making


Decisions made by military personnel in the field are similar in many ways to those made by practicing clinicians. They involve high stakes, outcomes are uncertain, and must be made in a limited amount of time.

Military decision making has been the subject of much theoretical and practical research. Given its similarity with clinical decision making, I think there is a lot to be gained from exploring how  the lessons learned from the study of military decisions can be used to improve the quality of clinical decisions, including how to effectively engage patients in shared decision making. 

Recently the Farnum Street Blog posted a description of a military decision making technique called the OODA loop.  [1] OODA stands for Observe, Orient, Decide, and Act. The technique was originally developed as a strategy to help fighter pilots survive aerial combat by U.S. Air Force Colonel John Boyd.

The key ideas insights of the OODA loop strategy are contained in the first two steps: Observe and Orient. 

The Observe phase involves gathering information about the current situation and correctly placing it in context by identifying what information is pertinent and what is not. 

The Orient Phase involves thinking clearly about the situation, the information available, and the decision(s) that need to be made. The Farnum post describes the Orient phase as follows: 

Orientation means connecting yourself with reality and seeing the world as it really is, as free as possible from the influence of cognitive biases and shortcuts.

One way to minimize the effects of cognitive biases on day to day decisions, first suggested by Charlie Munger and advocated by the Farnum Street folks, is to use a toolbox of mental models: practical tools and techniques that have been successfully used to improve decision making.

A mental model is simply a representation of how something works. We cannot keep all of the details of the world in our brains, so we use models to simplify the complex into understandable and organizable chunks. [2]

So, how could the OODA loop help us learn how to foster good clinical decisions and facilitate shared decision making in routine practice? Assuming a working relationship between clinician and patient has been established, the loop could proceed as follows:

Observe: A shared understanding of the nature of the decision is created that combines both the provider and the patient perspectives. This process includes establishing the goal of the decision, selecting the options to be considered, and identifying the considerations that will be used to judge how well the options can be expected to meet the goal. Once this framework is established, it is used to guide collection of decision-pertinent information and organize it in a format helps decision makers compare the options. 

Orient: The orientation phase consists of using one or more methods to minimize adverse effects of cognitive biases, emotional responses, and other factors on the decision making process. The mental model approach postulates that using one or more mental model technique to minimize these effects would facilitate the process and make it practical for use in real world situations. Farnum Street has a long list of mental models available that are worth reviewing. [2] Two core models of particular note for medical decision making include: 


Circle of competence: 

When you are honest about where your knowledge is lacking you know where you are vulnerable and where you can improve. Understanding your circle of competence improves decision-making and outcomes.

Probabilistic thinking:

Probabilistic thinking is essentially trying to estimate, using some tools of math and logic, the likelihood of any specific outcome coming to pass.

Decide: The decide phase involves choosing an option based on the insights provided by the Observation and Orient phases of the process.

Act: This phase is putting the decision made into action. A willingness to act suggests that decision making process is deemed rigorous and trustworthy. 

Musings

Although medical decision making is not the same as flying a fighter jet in combat, for patients the consequences of poor decisions can be as devastating as those experienced by fighter pilots. Learning how to incorporate the insights of the OODA loop and other military strategies into clinical decisions seems like a worthwhile undertaking. 

References

1. Farnum Street Blog: Decision Making.  https://fs.blog/category/decision-making/

2. Farnum Street Blog: Mental Models: The Best Way to Make Intelligent Decisions (~100 Models Explained) https://fs.blog/mental-models/#what_are_mental_models 

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