Is it possible to boost your decision-making competence through practice?
It is difficult to investigate how people make decisions in real-life situations characterised by uncertainty, urgency and inadequate information. Attempts to deconstruct such complexities tend to oversimplify the reality we want to study. Consequently, there is no compelling evidence to suggest that decision-making competence can be gained through practice. Despite inadequate corroboration, it does however seem reasonable to assume that such practice has an effect. For example, airlines and operational military units have long considered decision-making competence to be a key skill (1–6).
It has been suggested that in a medical context, such training might include theory classes combined with simulations and, most importantly, implementation in day-to-day practice (3, 4).
Having a basic understanding of decision theory entails being familiar with important decision-making models, the sources of error that influence us, and how we can prevent the bias they cause. Theoretical understanding can be built through self-study of relevant literature, discussion with colleagues and/or different forms of training – preferably starting while still at medical school (3, 4). This will provide a common framework of concepts and definitions.
Simulations and exercises have won an important place in medical training. There are training models that are, in addition to their purely medical content, intended to specifically provide practice in employing cognitive strategies (6). The simulation scenario should emulate our normal working environment and involve the same people. Case histories and feedback should deal with issues such as how clinical information is perceived, ignored and prioritised. This stimulates conscious choices and meta cognition: Why am I thinking the way I do (6)?
The matter of clinical implementation can be solved in various ways, and the organisation of day-to-day work routines should facilitate this. Self-monitoring helps us to recognise sources of error in our own decision-making processes and to apply cognitive strategies to minimise their impact. This can prevent potentially dangerous situations from arising. Experiencing and understanding that urgency and incomplete information is the norm, can help to reduce the level of frustration and the feeling of inadequacy. Good routines for continual and direct feedback on the effect of one's own assessments is a prerequisite for the development of expertise. Klein and Kahneman refer to this as a high-validity environment (5).
Concepts from decision-making theory can contribute to accurate communication in emergencies and when we retrospectively judge each other's decisions and try to analyse the basis on which they were made. This is especially the case when handling rare and/or undesirable incidents. Consequently, these are important tools for our work in quality improvement.
We should use and further develop procedures for situations that lend themselves to this type of approach. Procedures are highly appropriate if the patient's symptoms are limited and the treatment goal defined. Such procedures can ensure that patients quickly receive the correct treatment in cases of acute myocardial infarction or have their blood sugar level gradually corrected in cases of diabetic ketoacidosis. Good algorithms contribute to efficient treatment of trauma patients, and checklists minimise oversights. Procedures represent a good starting point for beginners but should not be a restrictive factor for experienced professionals who can identify more flexible solutions.
At the same time, we should avoid procedure-based practice wherever this is unhelpful (5). Procedures are often inappropriate in complex situations. Strict procedural thinking can lower the level of caution and professional interest among colleagues – thereby counteracting their objective over time (5). No collection of procedures can cover all eventualities. It is impossible to treat a seriously ill patient with a long case history, vague symptoms and poorly defined treatment goals by following a flow chart. Just as it is impossible for a pilot to look up the correct procedure when faced with landing an aircraft that has run out of fuel.
The results are decisive doctors, robust decisions and better treatment of patients.