Implications for improving clinical decisions
Lesson One: —
Beware of what you inherit. When someone presents something to you, the tendency is to make it slightly better than before rather than to ensure it’s the best solution in the first place.
Don’t do that.
When it comes to decision making, this means never letting anyone else define the problem for you. [1]
In recent decades, all medical decisions, even common, everyday ones, have become increasingly complex. Advancing technology has led to the creation of many new drugs, therapeutic modalities, and diagnostic tests. Multiple management options, none of which is clearly the most appropriate option for every patient, are now available for many clinical problems. Consequently there is an increased need for ensuring that options chosen are consistent with the preference and values of individual patients, the ones who ultimately will need to live with the outcomes of the choices made.
Despite a clear moral imperative to actively engage patients in making decisions about important choices affecting their health, current research studies have repeatedly shown that shared decision making is not widely practiced. As I’ve reviewed in previous Musings, currently proposed solutions to this problem have primarily consisted of modifications to the standard clinical dialog between patient and provider. Multiple modifications have been suggested and, so far, have had little impact. (2) It will be interesting to see if the additional suggestions included in the recent NHS Advice (discussed in the August 12, 2022) will make a difference.
In the October 10, 2022 Musing, I suggested using First Principles Thinking to facilitate uptake of shared decision making in clinical practice. In a recent Facebook post, posted on November 23, 2022, the Farnum Street Blog presented three lessons derived from First Principles Thinking which they defined as: “You break things down into the core parts and reassemble them in a more effective way.” [1] In the post, they liken first principles to LEGO blocks, items that cannot be reduced further that will be used to create a desired outcome.
I’ve quoted the first lesson in its entirety above. The second and third lessons advise breaking up a troublesome problem into it’s smallest components based on what is 100% true and then starting over. The First Principles hypothesis is that by taking a fresh approach, you are more likely to create a methodology that will achieve the desired outcome than repeatedly trying to tweak an existing approach that is not working.
Musing
It seems to me that all of the currently proposed solutions have failed to heed Farnum Street’s Lesson One of First Principles Thinking: they are trying to modify the traditional clinical interaction instead of first considering whether it is capable of adding shared decision making into an already complex decision making scenario. The lack of progress using this approach suggests something else needs to be done. An approach based on First Principles thinking seems well worth trying.
Reference
2. Stiggelbout AM, Pieterse AH, De Haes JC. Shared decision making: concepts, evidence, and practice. Patient Educ. Couns. 2015 Oct 1;98(10):1172-9.
mdm787 