Clinical Freedom and Decision Making: Navigating Complexity in Healthcare

1. “If things were simple, word would have gotten round.”Derrida - 1988 GP4 – Masterclass November 2001 Dr Alan Hassey

2. Clinical Freedom • The freedom to get things wrong? • The freedom to do things badly? • The freedom to act against patients’ best interests? • The freedom to evade clinical & professional responsibility? • The freedom to offer second-rate care?

3. The cost of clinical freedom • Harold Shipman • Bristol babies scandal • Rodney Ledward • Alder Hay post-mortem scandal • What about you….? • What about me….?

4. How we make decisions • Actuarial judgement is frequently better than clinical judgement • We are better at identifying & coding clinical data than we are at integrating and using it… • We are poor at estimating probabilities - we use heuristics which are generally useful but can lead to systematic errors & biases

5. Systematic errors or biases • Adjustment - the fallacy of inappropriate extrapolation - prognosis from previous experience • Availability - easily retrievable instances, people tend to prefer causative explanations • Superstition – unlikely events do not have any special significance • Cognitive conceit - the illusion of expertise • Representativeness - the problem of small samples

6. How we should make decisions • Application of probabilistic methods to clinical reasoning • Bayesian approach - modify our beliefs in the light of new evidence • Post test P = Pre test P x LR • What place for intuition? • Coping with complexity?

7. Clinical reasoning, decision analysis & support • Two main themes • The application of appropriate linear, probabilistic models to clinical reasoning • The application of expert judgement to clinical reasoning • Decision Support s/w can apply both statistical and expert judgement systems to the process of clinical care

14. So why health informatics? • Health informatics comprises the science of information management in health care and its application to support clinical practice, decision-making and research. • Triadic consultation • To bring the patient, doctor and relevant information together in such a way as to facilitate clinical care...

15. A cognitive dilemma Need to develop a new intellectual model to weave together these three strands: • The appropriate application of a scientific (probabilistic/linear) method & cognitive model - the traditional scientific clinical method. • The various narratives that make up the patient's health (illness) story • The unpredictable, intuitive, (Balint-like) flash of understanding (non-linear)

16. Hamm’s Cognitive Continuum • Formal deductive logic/experiment • Controlled trial with explicit degrees of uncertainty • Critical analysis & epidemiological data • System-aided model based on judgement • Peer-aided review • Intuitive (heuristic) judgement

17. Hospital Higher probability of disease Disease well-differentiated Disease separated from patient Biomedical labelling Diseases stay, patients come & go GP Lower probability of disease Disease poorly-differentiated Patient & illness inseparable No labels in 30% (+) Patients stay, diseases come & go The need for intuitive skills

18. Complexity • The DPR is a complex system • Some tasks are dealt with better by intuition • Analysis & recording tends to be reductionist (e.g. clinical codes) • Non-linear science allows us to consider narrative & intuition as part of clinical practice

19. Linear Traditional scientific method Left brain Logical cognitive model Hypothetico-deductive, pattern recognition Probabilistic Reductionist Evidence-based Quantitative Good for complicated problems Non-linear The “art” of medicine Right brain Intuitive cognitive model Interpretive, contextual Unpredictable (within boundaries) Holistic Narrative-based Qualitative Good for complex problems A new model for clinical method

20. Models in action Need to understand and apply a clinical method that incorporates • Best scientific evidence & cognitive model (alcoholism, poor diet, smoker) • An appreciation of illness narrative (family, sexual & work problems) • A model for the complexity (non-linearity) of the patient’s environment. (Patient as powerless victim, understanding of context)

21. Promoting intuitive skills • Level 7 of the cognitive continuum? • Suspend analysis • Intuitive mood • Non-judgemental awareness • 90% of communication is non-verbal • Clinician as healer (Balint > doctor as drug)

22. Decision support • Models • Rule-based (knowledge or probability) • Connectionist (emergent) • Holistic not problem-based • Narrative not codes • Input from non-verbal communication • Annotate & display whole model

24. Links to folk models of health & illness Narrative streams that are patient’s history Coded, H-D or P-R, reductionist model, “doctor-centred” Insight contextual understanding “patient-centred” Doctor as “healer” Family, work & sexual problems Self as “victim”, powerless, enhanced status after OD Alcoholic, smoker, self-neglect, attempted suicide Health interventions – physical, psychological, social Links to task models of health & illness Application of EB (Probabilistic) approach to health interventions