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Emergency Medicine Australasia (2014) 26, 295–299
doi: 10.1111/1742-6723.12210
PERSPECTIVE
Psychological factors in emergency medicine Marc GUTENSTEIN Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
Abstract Human psychology, neuroscience and behavioural economics study the human mind, brain and behaviour. Scientific research has discovered a great deal about the factors that influence human perception, judgment and activity in the real world. In this article, I aim to provide an outline of the relationship between decision-making, cognition, emotion and behaviour. I propose that meta-cognition, or thinking-about-thinking, has the potential to inform how we practice emergency medicine. By accommodating human traits rather than trying to defy them, we can ultimately benefit our patients. Key words: behavioural economics, decision-making, emergency medical service, emergency medicine, psychology.
Introduction Psychology as a philosophical enterprise is as old as human discourse itself. The modern project of psychology as a science is somewhat younger, emerging in the 19th century as a study of human behaviour. This century, enriched by neuroscience technologies, such as functional MRI scanning, and emboldened by computer science, psychology crosses many scientific boundaries and reaches into many spheres of human activity, including emergency medicine (Table 1). In this introduction to selected themes in psychology, I will argue that science has revealed that how we make
choices differs substantially from how we think we choose. I will argue that only by acknowledging this difference and catering to our human capabilities will we successfully make medicine a more rational enterprise.
of information, time and cognitive ability were acknowledged in the theory of bounded rationality, it was still proposed that given the right conditions, human beings ‘ought’ to be perfectly rational decision-makers.
Decision science and medical decision-making
Dual process theories: Intuition and reason
Throughout history, rationality – the ability to reason and make optimal decisions – has been a defining feature of the human mind. The history of this idea extends from ancient moral philosophy to modern artificial intelligence. In the last half-century, the study of human rationality and decisionmaking has been the domain of both cognitive psychologists and economists, both seeking to understand human choice from different perspectives. Whereas cognitive psychology seeks to understand thinking in terms of representations and computations in the mind, economics seeks to understand patterns of decision-making behaviour.
Unsurprisingly empirical research proved that human beings are frequently not rational and often fail to optimise the choices they make. The failure of this ‘cold’ cognition to account for real-world decisions, along with evidence that ‘hot’ cognition coloured by intuition and gut-feeling played a role in real decision-making, led to the development of dual process theories. Perhaps the most influential of these is that popularised by the book Thinking Fast and Slow.1 The basic concept is that cognition is served not by a single system but two parallel systems of information processing that can be discretely modelled in psychological tests and imaged using functional MRI. Whereas one system (system 1) is ‘hot’ and involves faster gut feelings and intuition, another system (system 2) is ‘cold’ and involves effortful calculation of verbatim information (Fig. 1). Crucially it is proposed that people often act intuitively, and it is this intuitive action of system 1 that more often leads to irrational behaviour. Indeed research shows that real-world thinking is actually characterised by predictable short cuts and errors – heuristics and biases. Just as visual illusions are perceptual errors that persist despite explanation, heuristics and biases can be considered decision-making illusions that are difficult if not impossible to avoid (Table 2). For example, when faced with a complex choice people usually take a default option, and when weighing up potential losses
Theories of rationality As originally conceived, cognition was considered a process of ‘cold’ analytical reasoning, quite separate to emotional and bodily states. Economic theory mirrored this philosophy. The idea that given all available information, human beings were able to make decisions that optimise any given outcome – so called rational optimisation – was hugely influential and became a cornerstone of modern economics. Even when the constraints
Correspondence: Dr Marc Gutenstein, Department of Emergency Medicine, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Marc Gutenstein, FACEM, FDRHMNZ, Emergency Physician. Accepted 19 December 2013
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
296
M GUTENSTEIN
TABLE 1.
Psychological domains and their relevance to emergency medicine
Cognitive psychology
Social and emotional psychology
Medical inquiry Clinical decision-making Risk perception Human factors and ergonomics Professional and team dynamics Doctor–patient relationship Compassionate healthcare Health beliefs and behaviour
Decision-making in emergency medicine These different cognitive and economic theories are of more than theoretical interest to emergency medical practice. We work in a rich and interconnected human environment that is prone to diagnostic and procedural errors. We have access to a huge body of medical literature, yet there is a gap between available health information, and the way real doctors and patients make decisions based on that information. The knowledge that we are steered by different types of thinking, and that we behave in predictable, albeit irrational ways, might allow us to improve our medical performance and enhance our rationality.
Cognitive forcing Figure 1.
Dual process theory.
against potential gains, people are predictably loss averse. Dual process theory is often discussed and debated and suffers from articles (such as this) that grossly simplify a very complex topic. In fact, there are many different descriptions of dual processes, and there is debate as to which cognitive style actually predominates in various real world settings.2 Fuzzy Trace theory proposes that an intuitive system is the prevailing system in adult health behaviour. A core idea of this theory is that people usually rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decisionmaking.3 Although the specific detail of this model remains contentious, it remains a useful narrative tool that reminds us that there are different sides to cognition.
Ecological rationality and evolutionary psychology One criticism of the previous model is a persisting assumption that, were it not for heuristics and biases, humans ‘ought’ to be perfectly rational. An alternative explanation is that these short
cuts are not necessarily failures of cognition but that in fact humans have evolved these features to be extremely efficient decision-makers using fast and frugal heuristics specific to action in different environments. Thus, humans can be considered as ecologically rational.4 Indeed from an evolutionary perspective, it is likely we did not evolve to think in isolation from action, but as biological organisms with real world choices to execute in order to survive. From this perspective, the seemingly irrational errors that people predictably make can be seen as ‘common sense’ adaptive survival strategies, exhibiting deep rationality.5
Dynamic decision-making The theories outlined above are useful when considering individual decisions, when there are pre-defined options and a ‘correct’ choice. In practice, the real world contains a series of complex, often interdependent decisions, evolving situations and time and resource limitations. The effort to model such scenarios in all their complexity is the discipline of dynamic decision-making.6
One common approach to reducing medical error in diagnosis and treatment has been to develop computerbased decision tools. In effect, these tools force the human user to become more rational. These projects have been successful in optimising medical and surgical care in some situations. However, these have mostly been welldefined clinical problems in nonemergent settings. Widespread adoption of decision support software has yet to occur in more dynamic situations, such as emergency medicine. Here a tension remains between idealised models of analytical thinking and the observed behaviour of doctors that often remains intuitive or reactive. It has not been firmly established which methods prevail in which circumstances.7 Another common approach has been to use checklists and algorithms. There is strong support for checklist use in medicine, after surgical research showed that simple checklists greatly enhance patient safety. This approach has been extended to common procedural tasks, such as Rapid Sequence Intubation. In keeping with this, a proposed general strategy for enforcing ‘cold’ analysis is to use metachecklists to de-bias decision-making, enhance meta-cognition and improve analytical thinking.8
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
297
META-COGNITION AND EMERGENCY MEDICINE
TABLE 2.
Common biases described and examples in medical decision-making
Loss aversion Attribution bias Default bias Availability bias Identifiable victim effect
Losses are more salient than gains Blame an individual rather than a situation Avoiding choice is more compelling than choosing Judge familiar things more frequent Individual outcomes more salient than groups
Figure 2. Imagine a disease with 10% risk of death and prevalence in the ED of 5%. A test with sensitivity 90% and specificity 90% is available to you. Treatment for the disease has been shown to reduce relative risk of death by 30% and carries a complication rate of 1%. Based on this information, would you go ahead and use the test? Abstracted, the test and treatment package sound promising. However, a naturalised representation of this approach shows that despite thousands of tests and hundreds of treatments, there is no net benefit.
TABLE 3. outcomes
Cognitive models and potential avenues for improving medical
Enhance ‘cold’ processes
Enhance ‘hot’ processes
Bayesian analysis Linear regression models Checklists Training in meta-cognition Gist communication Frugal heuristics and decision trees Behavioural ‘nudges’ and choice architecture Natural frequency risk communication
Naturalising cognition A complementary approach to the problem is to try and accommodate our natural cognitive style, rather than enforcing cold analysis. For example, statistical information, such as relative risks and Bayesian probabilities, are naturally difficult concepts. However, if translated into representations, such as numbers-needed-totreat or visual decision trees (Fig. 2),9 we can take advantage of our evolved rationality to make fast and accurate decisions. As medical technology
continues to advance, thereby changing the balance of risk and benefit for our patients,10 a naturalised approach such as this might help avoid the dangers of over-investigation and over-treatment. Many structured approaches to triage, resuscitation and critical care can be considered fast and frugal heuristics. These shift the focus from acquiring information to deciding about intervention. In general, this approach might be a better way of mapping emergency medical decisions, allowing doctors to more readily extract the
Refusal of treatment Complaints Low organ donor rates Diagnostic errors Treatment errors
bottom-line meaning from otherwise complex scenarios. Other possible cognitive interventions are shown (Table 3) and systematically reviewed elsewhere.11 In the long term, health informatics and big data promise to revolutionise how we practice medicine. The more sophisticated domain of dynamic decision-making might be capable of modelling a much wider range of clinical and cognitive processes, and development of natural user interfaces might encourage the uptake of these new technologies.
Social and emotional factors Of course emergency medicine consists of much more than technical decision-making. The consultation is as much a social interaction with emotion providing the principle currency. Again psychology and related science can help understand and improve this side of our practice.
Emotion, cognition and behaviour Research demonstrates a complex interplay between thinking, emotional states and behaviour.12 Popularised in the book Descartes Error13 is the theory that emotion and reason are both necessary for navigation in the real world, playing a particularly important role in social decision-making. Furthermore, emotions themselves are embodied physiological states with somatic markers guiding behaviour. In the ED, emotional influences surround us. Endogenous factors, environmental factors and features of the specific clinical situation are sources of emotional interference that affect not only how we feel, but also how we make decisions, our beliefs and the beliefs of our patients (Table 4).14 Only by attending to these can we control their influence
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
298
M GUTENSTEIN
through good design and workforce organisation. The theme of a complex interconnection between emotion and reason is extended further by research into moral and ethical decision-making. Neuroscientists have examined how mathematically identical situations can lead to inconsistent decisions (Table 5), and the evidence supports that it is the social and emotional content of our decisions that is the most salient factor.15 Similar ethical dilemmas exist in medicine when high-risk treatments are considered. Although emergency medicine is a highly utilitarian activity, it is served and received personally, and in the course of treating patients we knowingly will harm some individuals. What can result is an empathy gap in which we underestimate the ability of visceral drives to interfere
TABLE 4. Examples of emotional influences on decision-making Transitory emotional states Environmental stress Rostering and circadian fatigue Counter transference Attribution errors Mood and anxiety disorders
with our practice. Statistical evidence aside, the very highest risk treatments might seem even higher risk to the physicians personally delivering the treatment. Only by being aware of this we can implement systems to accommodate it – for example by using standardised pathways to distance high-risk treatment decisions from the actual delivery of the treatments.
Staff satisfaction Maintaining a medical workforce is crucial to the delivery of quality care, but as demonstrated by the movement of emergency physicians around the world, ostensibly similar workplaces can differ greatly in terms of staff morale, recruitment and retention. A large body of literature in behavioural economics, summarised in the book The Upside of Irrationality,16 informs us that workplace satisfaction is not solely the product of working hours and compensation. Other factors such as task completion, skill mastery and social acknowledgement, are equally powerful. A scientific approach can inform how we manage our workforce, from adapting rosters to optimise natural circadian rhythms, to ensuring the workplace maximises motivation and performance in the face of an intense and repetitive work environment.
Patient satisfaction and compassion behaviour Ultimately the test of a health system lies not just in utilitarian health outcomes but also in the patient experience. From the patient perspective, the truth of their illness is inextricably linked to their values, beliefs and biases. In a systematic review in emergency medicine, patient satisfaction was largely determined by staff attitude and interpersonal skills.17 A dissociation between technical care and patient satisfaction is well recognised in that complaints are often linked to failures of compassion or communication, and conversely many technical errors do not lead to complaints. There is an intriguing body of research that shows that the activity of engaging in deliberative decisionmaking might actually impair altruistic behaviour. If using ‘cold’ cognition actually makes it more difficult to use ‘hot’ processing, such as ethical reasoning and compassion, then optimising the patient experience might not just be a matter of discretionary effort but might also relate to the way we interact with medical information. As much as we would like to be more rational, we must be careful not to force out compassion along the way.
TABLE 5. The trolley problem: although logically identical the two scenarios elicit different responses and activate different brain areas on fMRI imaging SCENARIO 1 – A train hurtles down the tracks. Ahead are five people certain to get run down, unless the train switches to a different track where only one person is standing in the way. You are in the control room: Would you tell the driver to switch tracks? SCENARIO 2 – What if, as the train speeds down the track, the only way to save the five people is to push one unlucky man in front of the train, where his body will get caught in the wheels and bring it to a halt. You are standing beside him: Would you push him in front of the train?
TABLE 6.
Parallel clinical tasks, clinical reasoning behaviours and psychological processes in emergency medicine
Clinical tasks
Clinical reasoning behaviour
Psychological processes
Clinical assessment Diagnosis and specific therapy Resuscitation and supportive care Disposition and follow up
Medical inquiry Deductive reasoning Rule-based algorithms Event-based decisions Pattern recognition
Socio-emotional exchange Analytical thinking Heuristic thinking Intuitive thinking
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
299
META-COGNITION AND EMERGENCY MEDICINE
Summary Emergency medicine is best understood as consisting of parallel streams of clinical tasks, decision-making behaviour 18 and cognitive processes (Table 6), all of which are necessary for good technical outcome and patient satisfaction. By understanding human psychology, we can try to improve these processes. Of more than philosophical or theoretical interest, social and cognitive psychology and related disciplines show us that we deviate from idealised behaviour in predictable and intractable ways, limited not only by our will, but also by our neurobiology. Harnessing this knowledge has the potential to reduce clinical error and improve individual and systems performance, by anticipating human factors, encouraging meta-cognition and creating intelligently designed, ergonomic systems, and more sophisticated decision support tools. Furthermore, by jettisoning the ideal of doctors as coldly rational automatons, and instead optimising naturalistic decision-making, and appealing to our patients using gist and narrative, we stand to create a more intelligent, more compassionate workplace in the future.
Competing interests None declared.
References 1. Kahneman D. Thinking Fast and Slow. New York: NY Farrar, Straus and Giroux, 2011. 2. Sherbino J, Dore K, Wood T. The relationship between response time and diagnostic accuracy. Acad. Med. 2012; 87: 785–91. 3. Reyna V. A theory of medical decision making and health: fuzzy trace theory. Med. Decis. Making 2008; 28: 850. 4. Marewski JN, Gigerenzer G. Heuristic decision making in medicine. Dialogues Clin. Neurosci. 2012; 14: 77–89. 5. Kenrick DT, Griskevicius V, Sundie JM, Li NP, Li YJ, Neuberg SL. Deep rationality: the evolutionary economics of decision making. Soc. Cogn. 2009; 27: 764–85. 6. Fox J, Cooper R. A canonical theory of dynamic decision making. Front. Psychol. 2013; 4: 150. 7. Elstein A, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002; 324: 729–32. 8. Ely J, Graber M, Croskerry P. Checklists to reduce diagnostic errors. Acad. Med. 2011; 86: 307–13. 9. Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003; 327: 741–4.
10. Hoffman JR, Cooper RJ. Overdiagnosis of disease: a modern epidemic. Arch. Intern. Med. 2012; 172: 1123–4. 11. Graber M, Kissam S. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual. Saf. 2012; 21: 535–57. 12. Dolan RJ. Emotion, cognition, and behavior. Science 2002; 298: 1191. 13. Damasio A. Descartes Error: Emotion, Reason and the Human Brain. London: Vintage, 2006. 14. Croskerry P, Abbass A, Wu A. Emotional influences in patient safety. J. Patient Saf. 2010; 6: 199–205. 15. Greene J. From neural ‘is’ to moral ‘ought’: what are the moral implications of neuroscientific moral psychology? Nat. Rev. Neurosci. 2003; 4: 847–50. 16. Ariely D. The Upside of Irrationality: The Unexpected Benefits of Defying Logic at Work and at Home. London: HarperCollins, 2010. 17. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg. Med. J. 2004; 21: 528–32. 18. Chapman DM, Char DM, Aubin CD. Clinical decision making. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th edn. Philadelphia, PA: Mosby, 2005; 125–33.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2014) 26, 295–299
doi: 10.1111/1742-6723.12210
PERSPECTIVE
Psychological factors in emergency medicine Marc GUTENSTEIN Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
Abstract Human psychology, neuroscience and behavioural economics study the human mind, brain and behaviour. Scientific research has discovered a great deal about the factors that influence human perception, judgment and activity in the real world. In this article, I aim to provide an outline of the relationship between decision-making, cognition, emotion and behaviour. I propose that meta-cognition, or thinking-about-thinking, has the potential to inform how we practice emergency medicine. By accommodating human traits rather than trying to defy them, we can ultimately benefit our patients. Key words: behavioural economics, decision-making, emergency medical service, emergency medicine, psychology.
Introduction Psychology as a philosophical enterprise is as old as human discourse itself. The modern project of psychology as a science is somewhat younger, emerging in the 19th century as a study of human behaviour. This century, enriched by neuroscience technologies, such as functional MRI scanning, and emboldened by computer science, psychology crosses many scientific boundaries and reaches into many spheres of human activity, including emergency medicine (Table 1). In this introduction to selected themes in psychology, I will argue that science has revealed that how we make
choices differs substantially from how we think we choose. I will argue that only by acknowledging this difference and catering to our human capabilities will we successfully make medicine a more rational enterprise.
of information, time and cognitive ability were acknowledged in the theory of bounded rationality, it was still proposed that given the right conditions, human beings ‘ought’ to be perfectly rational decision-makers.
Decision science and medical decision-making
Dual process theories: Intuition and reason
Throughout history, rationality – the ability to reason and make optimal decisions – has been a defining feature of the human mind. The history of this idea extends from ancient moral philosophy to modern artificial intelligence. In the last half-century, the study of human rationality and decisionmaking has been the domain of both cognitive psychologists and economists, both seeking to understand human choice from different perspectives. Whereas cognitive psychology seeks to understand thinking in terms of representations and computations in the mind, economics seeks to understand patterns of decision-making behaviour.
Unsurprisingly empirical research proved that human beings are frequently not rational and often fail to optimise the choices they make. The failure of this ‘cold’ cognition to account for real-world decisions, along with evidence that ‘hot’ cognition coloured by intuition and gut-feeling played a role in real decision-making, led to the development of dual process theories. Perhaps the most influential of these is that popularised by the book Thinking Fast and Slow.1 The basic concept is that cognition is served not by a single system but two parallel systems of information processing that can be discretely modelled in psychological tests and imaged using functional MRI. Whereas one system (system 1) is ‘hot’ and involves faster gut feelings and intuition, another system (system 2) is ‘cold’ and involves effortful calculation of verbatim information (Fig. 1). Crucially it is proposed that people often act intuitively, and it is this intuitive action of system 1 that more often leads to irrational behaviour. Indeed research shows that real-world thinking is actually characterised by predictable short cuts and errors – heuristics and biases. Just as visual illusions are perceptual errors that persist despite explanation, heuristics and biases can be considered decision-making illusions that are difficult if not impossible to avoid (Table 2). For example, when faced with a complex choice people usually take a default option, and when weighing up potential losses
Theories of rationality As originally conceived, cognition was considered a process of ‘cold’ analytical reasoning, quite separate to emotional and bodily states. Economic theory mirrored this philosophy. The idea that given all available information, human beings were able to make decisions that optimise any given outcome – so called rational optimisation – was hugely influential and became a cornerstone of modern economics. Even when the constraints
Correspondence: Dr Marc Gutenstein, Department of Emergency Medicine, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand. Marc Gutenstein, FACEM, FDRHMNZ, Emergency Physician. Accepted 19 December 2013
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
296
M GUTENSTEIN
TABLE 1.
Psychological domains and their relevance to emergency medicine
Cognitive psychology
Social and emotional psychology
Medical inquiry Clinical decision-making Risk perception Human factors and ergonomics Professional and team dynamics Doctor–patient relationship Compassionate healthcare Health beliefs and behaviour
Decision-making in emergency medicine These different cognitive and economic theories are of more than theoretical interest to emergency medical practice. We work in a rich and interconnected human environment that is prone to diagnostic and procedural errors. We have access to a huge body of medical literature, yet there is a gap between available health information, and the way real doctors and patients make decisions based on that information. The knowledge that we are steered by different types of thinking, and that we behave in predictable, albeit irrational ways, might allow us to improve our medical performance and enhance our rationality.
Cognitive forcing Figure 1.
Dual process theory.
against potential gains, people are predictably loss averse. Dual process theory is often discussed and debated and suffers from articles (such as this) that grossly simplify a very complex topic. In fact, there are many different descriptions of dual processes, and there is debate as to which cognitive style actually predominates in various real world settings.2 Fuzzy Trace theory proposes that an intuitive system is the prevailing system in adult health behaviour. A core idea of this theory is that people usually rely on the gist of information, its bottom-line meaning, as opposed to verbatim details in judgment and decisionmaking.3 Although the specific detail of this model remains contentious, it remains a useful narrative tool that reminds us that there are different sides to cognition.
Ecological rationality and evolutionary psychology One criticism of the previous model is a persisting assumption that, were it not for heuristics and biases, humans ‘ought’ to be perfectly rational. An alternative explanation is that these short
cuts are not necessarily failures of cognition but that in fact humans have evolved these features to be extremely efficient decision-makers using fast and frugal heuristics specific to action in different environments. Thus, humans can be considered as ecologically rational.4 Indeed from an evolutionary perspective, it is likely we did not evolve to think in isolation from action, but as biological organisms with real world choices to execute in order to survive. From this perspective, the seemingly irrational errors that people predictably make can be seen as ‘common sense’ adaptive survival strategies, exhibiting deep rationality.5
Dynamic decision-making The theories outlined above are useful when considering individual decisions, when there are pre-defined options and a ‘correct’ choice. In practice, the real world contains a series of complex, often interdependent decisions, evolving situations and time and resource limitations. The effort to model such scenarios in all their complexity is the discipline of dynamic decision-making.6
One common approach to reducing medical error in diagnosis and treatment has been to develop computerbased decision tools. In effect, these tools force the human user to become more rational. These projects have been successful in optimising medical and surgical care in some situations. However, these have mostly been welldefined clinical problems in nonemergent settings. Widespread adoption of decision support software has yet to occur in more dynamic situations, such as emergency medicine. Here a tension remains between idealised models of analytical thinking and the observed behaviour of doctors that often remains intuitive or reactive. It has not been firmly established which methods prevail in which circumstances.7 Another common approach has been to use checklists and algorithms. There is strong support for checklist use in medicine, after surgical research showed that simple checklists greatly enhance patient safety. This approach has been extended to common procedural tasks, such as Rapid Sequence Intubation. In keeping with this, a proposed general strategy for enforcing ‘cold’ analysis is to use metachecklists to de-bias decision-making, enhance meta-cognition and improve analytical thinking.8
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
297
META-COGNITION AND EMERGENCY MEDICINE
TABLE 2.
Common biases described and examples in medical decision-making
Loss aversion Attribution bias Default bias Availability bias Identifiable victim effect
Losses are more salient than gains Blame an individual rather than a situation Avoiding choice is more compelling than choosing Judge familiar things more frequent Individual outcomes more salient than groups
Figure 2. Imagine a disease with 10% risk of death and prevalence in the ED of 5%. A test with sensitivity 90% and specificity 90% is available to you. Treatment for the disease has been shown to reduce relative risk of death by 30% and carries a complication rate of 1%. Based on this information, would you go ahead and use the test? Abstracted, the test and treatment package sound promising. However, a naturalised representation of this approach shows that despite thousands of tests and hundreds of treatments, there is no net benefit.
TABLE 3. outcomes
Cognitive models and potential avenues for improving medical
Enhance ‘cold’ processes
Enhance ‘hot’ processes
Bayesian analysis Linear regression models Checklists Training in meta-cognition Gist communication Frugal heuristics and decision trees Behavioural ‘nudges’ and choice architecture Natural frequency risk communication
Naturalising cognition A complementary approach to the problem is to try and accommodate our natural cognitive style, rather than enforcing cold analysis. For example, statistical information, such as relative risks and Bayesian probabilities, are naturally difficult concepts. However, if translated into representations, such as numbers-needed-totreat or visual decision trees (Fig. 2),9 we can take advantage of our evolved rationality to make fast and accurate decisions. As medical technology
continues to advance, thereby changing the balance of risk and benefit for our patients,10 a naturalised approach such as this might help avoid the dangers of over-investigation and over-treatment. Many structured approaches to triage, resuscitation and critical care can be considered fast and frugal heuristics. These shift the focus from acquiring information to deciding about intervention. In general, this approach might be a better way of mapping emergency medical decisions, allowing doctors to more readily extract the
Refusal of treatment Complaints Low organ donor rates Diagnostic errors Treatment errors
bottom-line meaning from otherwise complex scenarios. Other possible cognitive interventions are shown (Table 3) and systematically reviewed elsewhere.11 In the long term, health informatics and big data promise to revolutionise how we practice medicine. The more sophisticated domain of dynamic decision-making might be capable of modelling a much wider range of clinical and cognitive processes, and development of natural user interfaces might encourage the uptake of these new technologies.
Social and emotional factors Of course emergency medicine consists of much more than technical decision-making. The consultation is as much a social interaction with emotion providing the principle currency. Again psychology and related science can help understand and improve this side of our practice.
Emotion, cognition and behaviour Research demonstrates a complex interplay between thinking, emotional states and behaviour.12 Popularised in the book Descartes Error13 is the theory that emotion and reason are both necessary for navigation in the real world, playing a particularly important role in social decision-making. Furthermore, emotions themselves are embodied physiological states with somatic markers guiding behaviour. In the ED, emotional influences surround us. Endogenous factors, environmental factors and features of the specific clinical situation are sources of emotional interference that affect not only how we feel, but also how we make decisions, our beliefs and the beliefs of our patients (Table 4).14 Only by attending to these can we control their influence
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
298
M GUTENSTEIN
through good design and workforce organisation. The theme of a complex interconnection between emotion and reason is extended further by research into moral and ethical decision-making. Neuroscientists have examined how mathematically identical situations can lead to inconsistent decisions (Table 5), and the evidence supports that it is the social and emotional content of our decisions that is the most salient factor.15 Similar ethical dilemmas exist in medicine when high-risk treatments are considered. Although emergency medicine is a highly utilitarian activity, it is served and received personally, and in the course of treating patients we knowingly will harm some individuals. What can result is an empathy gap in which we underestimate the ability of visceral drives to interfere
TABLE 4. Examples of emotional influences on decision-making Transitory emotional states Environmental stress Rostering and circadian fatigue Counter transference Attribution errors Mood and anxiety disorders
with our practice. Statistical evidence aside, the very highest risk treatments might seem even higher risk to the physicians personally delivering the treatment. Only by being aware of this we can implement systems to accommodate it – for example by using standardised pathways to distance high-risk treatment decisions from the actual delivery of the treatments.
Staff satisfaction Maintaining a medical workforce is crucial to the delivery of quality care, but as demonstrated by the movement of emergency physicians around the world, ostensibly similar workplaces can differ greatly in terms of staff morale, recruitment and retention. A large body of literature in behavioural economics, summarised in the book The Upside of Irrationality,16 informs us that workplace satisfaction is not solely the product of working hours and compensation. Other factors such as task completion, skill mastery and social acknowledgement, are equally powerful. A scientific approach can inform how we manage our workforce, from adapting rosters to optimise natural circadian rhythms, to ensuring the workplace maximises motivation and performance in the face of an intense and repetitive work environment.
Patient satisfaction and compassion behaviour Ultimately the test of a health system lies not just in utilitarian health outcomes but also in the patient experience. From the patient perspective, the truth of their illness is inextricably linked to their values, beliefs and biases. In a systematic review in emergency medicine, patient satisfaction was largely determined by staff attitude and interpersonal skills.17 A dissociation between technical care and patient satisfaction is well recognised in that complaints are often linked to failures of compassion or communication, and conversely many technical errors do not lead to complaints. There is an intriguing body of research that shows that the activity of engaging in deliberative decisionmaking might actually impair altruistic behaviour. If using ‘cold’ cognition actually makes it more difficult to use ‘hot’ processing, such as ethical reasoning and compassion, then optimising the patient experience might not just be a matter of discretionary effort but might also relate to the way we interact with medical information. As much as we would like to be more rational, we must be careful not to force out compassion along the way.
TABLE 5. The trolley problem: although logically identical the two scenarios elicit different responses and activate different brain areas on fMRI imaging SCENARIO 1 – A train hurtles down the tracks. Ahead are five people certain to get run down, unless the train switches to a different track where only one person is standing in the way. You are in the control room: Would you tell the driver to switch tracks? SCENARIO 2 – What if, as the train speeds down the track, the only way to save the five people is to push one unlucky man in front of the train, where his body will get caught in the wheels and bring it to a halt. You are standing beside him: Would you push him in front of the train?
TABLE 6.
Parallel clinical tasks, clinical reasoning behaviours and psychological processes in emergency medicine
Clinical tasks
Clinical reasoning behaviour
Psychological processes
Clinical assessment Diagnosis and specific therapy Resuscitation and supportive care Disposition and follow up
Medical inquiry Deductive reasoning Rule-based algorithms Event-based decisions Pattern recognition
Socio-emotional exchange Analytical thinking Heuristic thinking Intuitive thinking
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
299
META-COGNITION AND EMERGENCY MEDICINE
Summary Emergency medicine is best understood as consisting of parallel streams of clinical tasks, decision-making behaviour 18 and cognitive processes (Table 6), all of which are necessary for good technical outcome and patient satisfaction. By understanding human psychology, we can try to improve these processes. Of more than philosophical or theoretical interest, social and cognitive psychology and related disciplines show us that we deviate from idealised behaviour in predictable and intractable ways, limited not only by our will, but also by our neurobiology. Harnessing this knowledge has the potential to reduce clinical error and improve individual and systems performance, by anticipating human factors, encouraging meta-cognition and creating intelligently designed, ergonomic systems, and more sophisticated decision support tools. Furthermore, by jettisoning the ideal of doctors as coldly rational automatons, and instead optimising naturalistic decision-making, and appealing to our patients using gist and narrative, we stand to create a more intelligent, more compassionate workplace in the future.
Competing interests None declared.
References 1. Kahneman D. Thinking Fast and Slow. New York: NY Farrar, Straus and Giroux, 2011. 2. Sherbino J, Dore K, Wood T. The relationship between response time and diagnostic accuracy. Acad. Med. 2012; 87: 785–91. 3. Reyna V. A theory of medical decision making and health: fuzzy trace theory. Med. Decis. Making 2008; 28: 850. 4. Marewski JN, Gigerenzer G. Heuristic decision making in medicine. Dialogues Clin. Neurosci. 2012; 14: 77–89. 5. Kenrick DT, Griskevicius V, Sundie JM, Li NP, Li YJ, Neuberg SL. Deep rationality: the evolutionary economics of decision making. Soc. Cogn. 2009; 27: 764–85. 6. Fox J, Cooper R. A canonical theory of dynamic decision making. Front. Psychol. 2013; 4: 150. 7. Elstein A, Schwarz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ 2002; 324: 729–32. 8. Ely J, Graber M, Croskerry P. Checklists to reduce diagnostic errors. Acad. Med. 2011; 86: 307–13. 9. Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. BMJ 2003; 327: 741–4.
10. Hoffman JR, Cooper RJ. Overdiagnosis of disease: a modern epidemic. Arch. Intern. Med. 2012; 172: 1123–4. 11. Graber M, Kissam S. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual. Saf. 2012; 21: 535–57. 12. Dolan RJ. Emotion, cognition, and behavior. Science 2002; 298: 1191. 13. Damasio A. Descartes Error: Emotion, Reason and the Human Brain. London: Vintage, 2006. 14. Croskerry P, Abbass A, Wu A. Emotional influences in patient safety. J. Patient Saf. 2010; 6: 199–205. 15. Greene J. From neural ‘is’ to moral ‘ought’: what are the moral implications of neuroscientific moral psychology? Nat. Rev. Neurosci. 2003; 4: 847–50. 16. Ariely D. The Upside of Irrationality: The Unexpected Benefits of Defying Logic at Work and at Home. London: HarperCollins, 2010. 17. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg. Med. J. 2004; 21: 528–32. 18. Chapman DM, Char DM, Aubin CD. Clinical decision making. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 6th edn. Philadelphia, PA: Mosby, 2005; 125–33.
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