What is a good decision?

The key to improving patient care is focusing on ways to improve the clinical decision-making process.

At the most basic level, the objective of clinical decision making is to make good decisions regarding the care of individual patients. Before we can understand the implications of this statement further, we have to first address the question of what a good decision is.

There are two ways to evaluate a decision. One can judge the quality of a decision based on the outcome – what subsequently happens – or the process – how the decision was made.

There is good evidence that people commonly judge decisions by their outcomes. A decision followed by a favorable outcome is considered good and one followed by a poor outcome is considered bad. [1,2]  However, judging the quality of a decision by its outcome is only appropriate when the outcomes that will follow each option are known at the time the decision is made and this information is available to the decision maker(s).

When the potential outcomes are uncertain, good outcomes can follow poor decisions and vice versa. For example, one can arrive safely home after choosing to drive home after drinking too much alcohol and be involved in an accident when riding home in a taxi. However, choosing to drive yourself is still not a good choice since the chances of arriving home safely are much higher if you call for a ride. Annie Duke provides a great, real world example the dangers of judging a decision by its outcome (called resulting in poker) in Chapter 1 of her book “Thinking in Bets”, which is included in the free preview on Amazon.com. (Apologies to non-football fans.)

Judging decision choices by their outcomes is not appropriate when the future outcomes are uncertain. In this situation, whether a decision should be considered “good” or “bad” depends on how well it was made, i.e., the decision-making process. Because the majority of clinical decisions are made when the outcomes are uncertain, the key to improving patient care is focusing on ways to improve the clinical decision-making process.

Musings

If one accepts the premise that the goal of clinical decision making is to make good decisions regarding the care of individual patients, it follows that clinicians should be trained (and expected) to be expert decision makers. I don’t think this is widely recognized as a key element in the training of future clinicians. I think it should be.

It also follows that patients should also have decision making expertise. Ideally, learning how to make good decisions should be part of a basic high school education. Since it isn’t (as far as I know), developing and implementing methods to effectively guide patients through the clinical decision making process should be recognized as a key quality of care target metric.

References

1. Baron J, Hershey JC. Outcome Bias in Decision Evaluation. Journal of personality and social psychology. 1988;54(4):11–11.
2. Kausel EE, Ventura S, Rodríguez A. Outcome bias in subjective ratings of performance: Evidence from the (football) field. Journal of Economic Psychology. 2019;75:102132–102132.