How clinical decisions are made

Abstract

There is much variation in the implementation of the best available evidence into clinical practice. These gaps between evidence and practice are often a result of multiple individual decisions. When making a decision, there is so much potentially relevant information available, it is impossible to know or process it all (so called ‘bounded rationality’). Usually, a limited amount of information is selected to reach a sufficiently satisfactory decision, a process known as satisficing. There are two key processes used in decision making: System 1 and System 2. System 1 involves fast, intuitive decisions; System 2 is a deliberate analytical approach, used to locate information which is not instantly recalled. Human beings unconsciously use System 1 processing whenever possible because it is quicker and requires less effort than System 2. In clinical practice, gaps between evidence and practice can occur when a clinician develops a pattern of knowledge, which is then relied on for decisions using System 1 processing, without the activation of a System 2 check against the best available evidence from high quality research. The processing of information and decision making may be influenced by a number of cognitive biases, of which the decision maker may be unaware. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making. Increased understanding of decision making processes and common sources of error should help clinical decision makers to minimize avoidable mistakes and increase the proportion of decisions that are better.

10 years of mindlines: a systematic review and commentary

“…For example, several authors referred to mindlines as a form of system 1 (intuitive) as opposed to system 2 (analytical) thinking in articles on clinical information processing and cognitive errors [33-35]. Bate et al explain:

‘Dual process theory states that humans process information in two ways, termed System 1 and System 2.

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Examining the Role of the Health Care Professional in Controlling the Tobacco Epidemic: Individual, Organizational and Institutional Responsibilities

“…This principle, termed 'satisficing', has been identified as the dominant process at play in response to a number of implementation challenges. For example, it is clear that managers who work in publicly funded health care institutions first consider their first-hand knowledge of organizational idiosyncrasies when engineering responses to regulatory mandates, and only later integrate external knowledge such as research and guidelines [60,61]. Satisficed solutions encourage continuation of behaviors that fall short of optimal effectiveness [62,63].…”

Potential Social, Environmental, and Regulatory Threats to Electronic Health Record Strategies for Improving Tobacco Treatment in Healthcare

“…For example, it is clear that managers who work in publicly funded healthcare institutions first consider their first-hand knowledge of organisational idiosyncrasies, and only later integrate external knowledge such as research and guidelines. Discrepancies between these two sources of information are frequently resolved through satisficing (Bate et al, 2012;Macdonald et al, 2008). Far from faulty reasoning, satisficing is often a reliable design strategy when exclusively considering efficiency.…”