Soccer decision making insights for clinical decision makers. A free kick.

There seems to be a specific adaptation of cognitive skills to sports-related decision making under pressure. [1]

In recent musings, I’ve been advocating teaching clinicians and patients how to be better decision makers to improve the overall quality of healthcare and foster shared decision making. In the October 4, 2022 Musing, I listed several useful takeaways derived from successful decision support interventions in other fields. Another place I’ve recently found ideas applicable to clinical decision making is the field of decision-making in sports.

In 2021, Gregory Petiot and colleagues published an article titled: Key characteristics of decision making in soccer and their implications. [1] The paper reviews literature that supports the premise that that during a game, good soccer players do not rely solely on intuitive decision making processes. Rather better players learn, and can be taught, to use a combination of rapid intuitive decision making and a streamlined deliberative process:

“Similarly, recognition, evaluation, and judgment seem to be processing mechanisms that promote better decision making as long as they are light and adapted to the constraints of the context of play and to the changing, uncertain nature of play.” [1]

Pettiot and colleagues also point out that soccer players usually have multiple options available to them. They suggest that the decisions soccer players make should not be classified as right or wrong but rather as whether or not they are coherent, i.e., decisions that support the overall team strategy for winning the game.

Like soccer players, clinical decision makers often must make decisions quickly, for example when a patient is unstable or due to the time pressures of a busy clinical setting. Clinical and soccer decisions are also similar in that, most of the time, several people are working together as a team to achieve a common objective. In healthcare, the primary teammates are the clinician and the patient; occasionally others will also be involved.

Musings

To me, this paper provides three key insights applicable to clinical decision making:

a) Decision making processes can and should be adjusted to be appropriate for the context in which they are being used.
In healthcare, variables that define the decision making context include the nature of the problem, the urgency of the situation, the stakes involved, the amount of information available, the patient-clinician relationship, and, as suggested in the January 27, 2023 Musing, the Cynefin framework decision making scenario.

b) Powerful deliberative decision making methods can be utilized in dynamic, time limited situations if they are appropriately modified.
Intuitive decision making processes are fast and require little thought, but are subject to cognitive biases and can be adversely affected by emotional states. Deliberative decision making is slower, less susceptible to bias, more likely to reflect current knowledge, and better able to address uncertainty. The soccer-related findings suggest that elements of the deliberative process can be successfully adapted for use in situations where decisions must be made even as quickly as those made by soccer players during the course of a game. It also suggests that the skills can be taught.

c) When more than one individual is involved, good decisions are choices expected to help achieve a shared goal.
In other words, all decisions involving patients should contribute to helping them achieve a healthcare goal. An important initial step in caring for a patient is establishing the goal being sought. The method the patient/clinician team uses to achieve the shared goal – the team strategy – should be adapted to fit the decision making context. From this perspective shared clinical decision making is not a separate entity; all clinical decisions should be shared. Actively engaging patients in shared decision making is a decision making strategy used to meet the demands of a specific decision making context. Fostering adoption of shared decision making in clinical practice therefore depends on improving the abilities of patients and clinicians to understand clinical decision making strategy and tactics.

Note:

The origin of the term soccer is fascinating, see references 2 and 3.

References

1. Petiot GH, Bagatin R, Aquino R, Raab M. Key characteristics of decision making in soccer and their implications. New Ideas in Psychology. 2021 Apr;61:100846.
2. Why Is Soccer Called “Soccer” Instead of Being Called “Football”? [Internet]. Soccermodo. 2021 [cited 2023 Feb 7]. Available from: https://soccermodo.com/why-is-soccer-called-soccer/
3. Why Do Some People Call Football “Soccer”? | Britannica [Internet]. [cited 2023 Feb 7]. Available from: https://www.britannica.com/story/why-do-some-people-call-football-soccer

Is routine shared decision making a pipe dream or a realistic possibility?

“Shared decision-making is widely accepted as a core feature of good healthcare.” [1]

“All in all, the results show it is unlikely that SDM will become implemented in US cancer care without structural and policy changes that tackle the current economic barriers towards the approach.” [2]

Over the past 2 weeks, I have read two articles that present a striking contrast about the prospects for making shared decision making (SDM) a routine part of healthcare.

The first is an article by Chris Carmona and colleagues in the BMJ summarizing a new NICE guideline about how to incorporate shared decision making into routine practice. [1]

The article begins with a reminder that Principle 4 of the United Kingdom National Health System (NHS) constitution states: “Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.” The article then summarizes the recommendations included in the guideline for how institutions can support shared decision making and incorporate it into patient flow, the use of patient decision aids, and risk communication.

A number of comments regarding implementation of the guideline recommendations are also mentioned, including:
• Implementing shared decision is a complex tasks that requires high level organizational support.
• Shared decision making may require longer visit times and thereby reduce practice income, but any loses will be offset by ensuring “the right decisions are made with people”.

The second article was published last year by Isabelle Scholl, Sara Kobrin, and Glyn Elwyn who investigated system-level barriers to shared decision making in the care of cancer patients in the United States. [2] The authors report information gleaned from 30 semi-structured interviews conducted with a diverse sample of people involved in the care of cancer patients in the US healthcare system. Their main finding was that concern that shared decision making will result in loss of practice revenue and health professional income is a major barrier impeding adoption of shared decision making in cancer care. They conclude that:

“All in all, the results show it is unlikely that SDM will become implemented in US cancer care without structural and policy changes that tackle the current economic barriers towards the approach.”

Comments and reflections

Thus, while the authors of the NICE guideline believe possible revenue losses that result from implementing routine shared decision making will be offset by higher quality patient care, the respondents in the US study seemed to view the possible revenue losses associated as an insurmountable barrier to implementation of routine SDM barring major structural reform of the entire US healthcare system.

Does this mean that shared decision making is a nice idea but will never become a routine feature of healthcare in the US? Should everyone in the US interested in helping SDM become the standard of practice move to the UK? Or do these contrasting points of view provide important information about what is needed to overcome the current barriers to SDM implementation?

It seems to me that the respondents in the US study all assumed that practicing SDM results in loss of revenue. Is this really true? They also assumed a major restructuring of the entire health care system was needed, but what if SDM could be made practical and financially realistic with smaller, more incremental changes in the way things are currently done?

I do not think the situation is hopeless. Rather, I think the take-home message of these two studies is that we need to know more about how to make SDM feasible, financially viable, and acceptable within the constraints of any given healthcare system and that key constraints include the prevailing culture as well as economic and structural issues. Traditional, reductionist research alone will not get the job done. We need to think more broadly and creatively.

References

1. Carmona, Chris, Joseph Crutwell, Marie Burnham, and Louisa Polak. “Shared Decision-Making: Summary of NICE Guidance.” BMJ 373 (June 17, 2021): n1430. https://doi.org/10.1136/bmj.n1430.
2. Scholl, Isabelle, Sarah Kobrin, and Glyn Elwyn. “‘All about the Money?’ A Qualitative Interview Study Examining Organizational- and System-Level Characteristics That Promote or Hinder Shared Decision-Making in Cancer Care in the United States.” Implementation Science 15, no. 1 (September 21, 2020): 81. https://doi.org/10.1186/s13012-020-01042-7.

Happy Holidays

Best wishes for to all for a healthy and happy holiday season.

Warm regards,

Jim Dolan and the rest of the crew at Busara Analytics.

Invitation to review a new book on diagnostic testing

I’ve written a new book on diagnostic reasoning called: How to understand and use diagnostic tests. It’s meant to be a short, accessible introduction to the diagnostic process suitable for clinicians and interested patients.  A brief description is below.

The first edition of the book (May 2019) is available for free. Electronic copies of this book are available in both  EPUB file and MOBI (for Kindle) formats at the following links:

• EPUB file
• Kindle file

(See below for instructions for how to open both file types.)

These files are also available at the book website. If the link does not work, search for this address in your browser: https://busaraanalytics862194081.wordpress.com/.)

The book can also be accessed over the Internet by following this link. (If the link does not work, search for this address in your browser:  https://diagnosisprimer.pressbooks.com/)

Please note: This book is a work in progress, so please send your comments and suggestions and share it with your friends and others who you think might be interested in it. We’d love to obtain feedback from as many people as possible.

The easiest way to submit comments is via email sent to either jdolan787@gmail.com or  busaraanalytics@hotmail.com. You can also enter comments on the book website.

Book description

An accurate diagnosis is an essential component of good medical care. All diagnoses are initially uncertain. In some cases, the presenting signs and symptoms are distinctive enough to make a diagnosis with a high degree of certainty. In others, however, the cause of the presenting signs and symptoms is less clear-cut. In these situations, information obtained from one of more diagnostic tests can resolve much of the uncertainty about the cause of the patient’s symptoms. However, many commonly used diagnostic tests cannot resolve diagnostic uncertainty completely because they sometimes give false positive and false negative results. The key to understanding the diagnostic process is recognizing that uncertainty often exists and learning how to manage it. The goal of this primer is to help practitioners and patients achieve this level of understanding.

EPUB file

EPUB is short for electronic publication. The EPUB format is the standard electronic book format of the International Digital Publishing Forum. EPUB files can be opened by a large number of software programs and readily converted into PDF files if desired.

Reading an EPUB file on a Mac or IOS device

      The simplest approach is to use iBOOKS. iBOOKs included in the operating system installed on both types of devices and is the default EPUB reader on both. In addition to being a reader it has a library function that collects and catalogs all readable files on the device. It is easy to use and works well. Highly recommended.

Reading an EPUB file on Windows

      Microsoft Edge, automatically installed as part of Windows 10, will open an EPUB file automatically and is the easiest approach to reading a single EPUB file on a computer running Windows 10. The one drawback is there is no library function, that collects readable files on the device. Good alternatives that also include library capabilities are Calibre and Adobe Digital Editions. Both run on multiple operating systems, including older editions of the Windows operating system.

Additional information about reading EPUB files can be found at this link.

MOBI File

            Mobi files can be read using an Amazon Kindle, either on a stand-alone Kindle device or the Kindle reader apps that are available to all commonly used devices. In addition to being a reader, the Amazon Kindle applications also include library functions and syncing across devices. For further information, please visit the Amazon Kindle reader page.

Thanks.

Annals of SDM, #2. Isn’t it about decision making?

The updated Cochrane review of interventions for increasing the use of shared decision making by healthcare professionals included 87 studies. None worked.

Only 7 (8%) reported using a study framework related to decision making (6 Ottawa decision support framework and 1 3-step model for SDM). The rest mostly concentrated on behavioral change theories.

I wonder what would happen if we simply taught healthcare professionals how to improve their decision making skills instead.

Ref:

Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database of Systematic Reviews [Internet]. 2018;(7).

 

Annals of SDM, number one

An international group of 25 experts met in 2012 to develop a set of core competencies clinicians should master in order to successfully engage patients in shared decision making. The group was unable to achieve consensus about what shared decision making consists of. Not surprisingly, they were also unable to identify a set of core competencies beyond skills in relating to patients and risk communication.

A web of science citation search on July 31, 2018 found that this article has been cited 22 times.

Legare F, Moumjid-Ferdjaoui N, Drolet R, Stacey D, Haerter M, Bastian H, et al. Core Competencies for Shared Decision Making Training Programs: Insights From an International, Interdisciplinary Working Group. J Contin Educ Health Prof. 2013 Sep;33(4):267–73.

The Annals of SDM (shared decision making) is a series of small reports highlighting published information about the current practice of shared medical decision making. These reports are not intended to be all inclusive. Instead, they are designed to increase awareness of issues regarding SDM that may be of interest to those interested in this topic. Comments and suggestions for additions to this series are welcome.

Let’s modernize the formatting and presentation of systematic reviews

In an article just published in Implementation Science, a group of Canadian authors present the results of a mixed methods study that obtained feedback from 202 Canadian health care managers and policy makers regarding their use of published systematic reviews. (1) The majority of respondents noted major problems with the way most systematic reviews are currently reported. 76% indicated they would be more likely to use reviews in their daily work if they were provided with a short summary focused on the “take home message”. Unfortunately, there was little agreement among respondents about the best way to format a more useful systematic review reporting format.

There are several take-away messages from this article that I think are worth sharing.

The first is the reference to a purpose-based knowledge classification system proposed by Straus and colleagues. (2) This system uses three knowledge categories based on how the knowledge is used: conceptual, instrumental, and persuasive. Conceptual and persuasive knowledge are similar in that they change or add to existing mental models but do not alter practice. Instrumental knowledge on the other hand is used to change practice. This framework highlights the importance of defining the knowledge objective(s) to be achieved when designing the most appropriate presentation format for systematic reviews and similar knowledge summarization projects.

The second take away point is the study participants’ lack of interest in content that would support the validity of the information being presented such as the methods used to select the articles included in the summary and the likelihood that the study results could be biased. These issues are the core of information trustworthiness. That a group of individuals responsible for guiding health services and health care practices failed to appreciate the importance of ensuring that decisions are based on valid and reliable evidence is scary and points to a key need for some remedial continuing professional education.

Finally, and most importantly, I think one of the key premises underlying the project is out of date. Although not stated explicitly, it appears that the authors are seeking to develop and test in a subsequent randomized controlled trial a new format for providing static, printed research summaries that will increase their utilization by health care managers and policy makers. (Note that this is despite the fact that there was much variability in preferred format demonstrated by the participants in this study.) My question is why is there a need to constrain the presentation of research syntheses to a single, written format? Why don’t we have multiple formats, each designed to meet the needs of different end users using enhanced interactive media delivered over the Internet? We live in the 21st century. We should be seeking to understand how we can utilize the new technology available to us to make the products of our research more accessible and useful for end users.

 

1. Marquez C, Johnson AM, Jassemi S, Park J, Moore JE, Blaine C, et al. Enhancing the uptake of systematic reviews of effects: what is the best format for health care managers and policy-makers? A mixed-methods study. Implementation Science. 2018 Jun 22;13:84.
2. Straus, Sharon E., et al. “Monitoring use of knowledge and evaluating outcomes.” Canadian Medical Association Journal182.2 (2010): E94-E98.

Wicked problems

Wonderful post by Lorien Pratt about suggesting a new way forward in promoting our understanding and improving the decisions we make.

I am increasingly beginning to wonder if the 2 fields I follow most closely, medical decision making and health services research, are making a mistake by slowly adopting this perspective.

Marching to the beat of a different drummer

For a long time I have admired Malcolm Gladwell. He is a terrific writer with a gift for making complex ideas understandable to the general public, even though I don’t always agree with his conclusions. If you like how he writes, I suggest you hear him speak – he is just as good if not better. I first heard him speak at a Society for Medical Decision Making meeting several years ago. He gave a wonderful presentation without slides – very refreshing at a scientific conference overflowing with powerpoint – and excelled during the open question and answer period. I was therefore very excited to learn that he has a new podcast called “revisionist history“.

I started with episode 3 “the big man can’t shoot” which is about why Wilt Chamberlain, refused to shoot free throws underhanded, even though he doubled his free throw percentage during a short time he used this technique and there was clear evidence that it is the most accurate way to shoot free throws, at least per Rick Barry (also interviewed in the podcast). Wilt is not alone in this regard.  Shaquille O’Neil , LeBron  James, and  almost every other NBA player have not adopted this approach even though it could help their teams win games.

The hypothesized reason, attributed to the threshold model of group behavior posited by Mark Granovetter, is that all of these players have a high threshold for conforming to group norms. Because the group looks on underhand free throws as silly or “shooting like a sissy”, most players resist trying it because the influence of the group norm is stronger than their motivation to accomplish other objectives (like scoring points and winning games). Rick Barry on the other hand, a NBA hall of famer who played about the same time as Wilt Chamberlain, always shot free throws underhand and had a free throw percentage in the upper 90’s. It is clear from the episode that he had much less regard for group norms and was willing to go against the status quo to achieve other goals.

Coincidentally, the day after I listened to this I came across another example of a major sports person willing to do things differently because it works: Joe Maddon, manager of the Chicago Cubs. In an extra-innings  game earlier this week, he had a pitcher play the outfield. By having 2 pitchers in the lineup he could optimize the matchups with opposing batters without constantly changing pitchers and losing players eligible to keep playing.

This threshold model seems similar to status quo bias and possible other proposed explanations for why people tend to “do things they way they always do it” instead of trying a new approach, even if there is good evidence that the new approach will work better. It also seems related to concepts of inventiveness and creativity. In any case, I wonder how many opportunities are lost as a result of overly high thresholds for changing models of patient care and medical decision making. I also wonder if a multi-criteria framework that clearly identifies the goal of a decision and the objectives to be achieved would help adjust poorly calibrated thresholds to more appropriate levels.