Naturalistic Decision Making and the Practice of Health Care

Abstract

A recent essay in this journal identified health care as a fertile domain for extending the reach of naturalistic decision making (NDM). It targeted the "best practices regimen, " a host of initiatives begun in the late 20th century that address problems in service delivery, skyrocketing costs, and impediments in transforming products of basic science into effective treatments. Of particular importance are efforts to base treatment decisions on empirical research findings and to gauge the quality of decisions by their conformance to evidence-based practices. The challenges that the essay identified and the ways of addressing these challenges are well known in the health care community. They have had limited impact owing to several factors, including how advocates of the best practices regimen envision clinical decision making and their tendency to equate the exercise of skill with resistance to change. This paper describes the regimen's concept of decision making and its principles and deficiencies. It also identifies a conundrum: oversimplification prevents complexity from being recognized; as a result, evidence-based recommendations frequently have unforeseeable and deleterious consequences. The paper proposes that NDM is well positioned to address these problems and make a valuable contribution to health care practice. It illustrates NDMbased theories and concepts with a research example and describes their ability to address complex issues that arise in treating chronic illnesses.

Medical teamwork and the evolution of safety science: a critical review

“…Oftentimes, the most fundamental advances were based on the empirical identification of treatment strategies, and the randomized controlled trial (RCT) has become the "de facto evidential gold standard" (Catchpole and Alfred 2018). While viewing RCTs as the ideal methodology for causal inference, the quest for 'evidence-based medicine' has created an increased dependency on ostensibly objective data, and controversies about where to position medicine in the scientific landscape of 'hard' and 'soft' sciences are ongoing (Deaton and Cartwright 2018;Falzer 2018;Feinstein and Horwitz 1997;Klein et al 2016). It is also important to consider how this discourse takes place in a society that is increasingly reluctant to accept gaps in knowledge, attribute circumstance to fate or higher religious powers, or accept physicians that simply cannot explain disease, suffering and death.…”

Physician Judgment and Clinical Practice Guidelines

“…This article is a commentary on "Naturalistic Decision Making and the Practice of Health Care" by Paul R. Falzer in this special issue. Falzer (2018) and Klein, Woods, Klein, and Perry (2016) have called attention to the fact that external payers (insurance companies, government programs) may reward or penalize individual physicians or clinical groups depending on whether their behavior accords with the recommendation of an evidence-based clinical practice guideline (EB-CPG). (Klein et al [2016] call this the "best practices regimen," but to avoid confusion with a methodology focused on design of exemplary and successful approaches for accomplishing clinic tasks [Mold & Gregory, 2003], we will refer to "enforced conformance" to EB-CPG).…”

NDM and Healthcare Guidelines: More Attention to the Current Status, Complexity, and Context Is Needed

“…In this issue, Dr. Falzer (2018) contributes an article titled “Naturalistic Decision Making (NDM) and the Practice of Health Care.” He argues that the “best practices regimen”—an approach based on evidence and guidelines—has not worked due to a fundamental fallacy that they are overly simplistic and do not account for the nuances of modern medicine in the way that NDM could. He further asserts that implementation science approaches have not helped because they only serve to support and perpetuate the flawed “best practices regimen” approach.…”