The Decision Book 50 Models For Strategic Thinking Epub 11
Ashlie Hagenson
The recent 'outburst' of COVID-19 spurred efforts to model and forecast its diffusion patterns, either in terms of infections, people in need of medical assistance (ICU occupation) or casualties. Forecasting patterns and their implied end states remains cumbersome when few (stochastic) data points are available during the early stage of diffusion processes. Extrapolations based on compounded growth rates do not account for inflection points nor end-states. In order to remedy this situation, we advance a set of heuristics which combine forecasting and scenario thinking. Inspired by scenario thinking we allow for a broad range of end states (and their implied growth dynamics, parameters) which are consecutively being assessed in terms of how well they coincide with actual observations. When applying this approach to the diffusion of COVID-19, it becomes clear that combining potential end states with unfolding trajectories provides a better-informed decision space as short term predictions are accurate, while a portfolio of different end states informs the long view. The creation of such a decision space requires temporal distance. Only to the extent that one refrains from incorporating more recent data, more plausible end states become visible. Such dynamic approach also allows one to assess the potential effects of mitigating measures. As such, our contribution implies a plea for dynamically blending forecasting algorithms and scenario-oriented thinking, rather than conceiving them as substitutes or complements.
Parallel dual processing models of reasoning posit two cognitive modes of information processing that are in constant operation as humans reason. One mode has been described as experiential, fast and heuristic; the other as rational, conscious and rule based. Within such models, the uptake of new research evidence can be represented by the latter mode; it is reflective, explicit and intentional. On the other hand, well practiced clinical judgments can be positioned in the experiential mode, being automatic, reflexive and swift. Research suggests that individual differences between people in both cognitive capacity (e.g., intelligence) and cognitive processing (e.g., thinking styles) influence how both reasoning modes interact. This being so, it is proposed that these same differences between doctors may moderate the uptake of new research evidence. Such dispositional characteristics have largely been ignored in research investigating effective strategies in implementing research evidence. Whilst medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgment still retains a key position in terms of diagnostic and treatment decisions for individual patients. This paper argues therefore, that individual differences between doctors in terms of reasoning are important considerations in any discussion relating to changing clinical practice.
It is imperative that change strategies in healthcare consider relevant theoretical frameworks from other disciplines such as psychology. Generic dual processing models of reasoning are proposed as potentially useful in identifying factors within doctors that may moderate their individual uptake of evidence into clinical decision-making. Such factors can then inform strategies to change practice.
Theories relate to the individual (e.g., cognitive and educational theories), social interaction and context (e.g., social learning theory), and organisational and economic contexts (e.g., theories of innovative organisations) [4]. Our interest lies in considering a group of theories from within the psychological research tradition relating to the individual doctor. We suggest that parallel dual processing models of reasoning potentially are useful in identifying factors that influence the uptake of new evidence by individual doctors. Firstly we describe the nature of parallel dual processing models of reasoning, then discuss the uptake of best evidence by clinicians within the context of these, and go on to summarise some of the individual differences in cognitive processing that may influence the uptake of evidence by doctors. The implications of differences in thinking dispositions for implementation science and medical education are then considered.
Dual processing models of reasoning have been conceptualised in two ways. First, reasoning can be either-or, where experiential processing is chosen in circumstances of low motivation; for example, when a judgement is considered relatively unimportant. Conversely, rational processing is chosen when the stakes are high. The Heuristic-Systematic Information Processing Model is an example of an either-or account, where a decision maker uses either simple decision rules (referred to as heuristic), or a systematic approach, with the choice being mediated, for example, by the degree of involvement the person has with the decision [10]. Such either-or models may not accommodate clinical decision-making well, because they position underlying motivation as the determinant of a person's processing mode. It would be difficult to argue, for example, that doctors making decisions in the experiential mode are less motivated to make correct diagnoses than those operating in the rational mode.
If, as has been argued elsewhere, the time has come to consider various theoretical bases from other disciplines for evidence-based implementation strategies in medicine [2], there would appear to be a prima-facie case for considering parallel dual processing models of reasoning. Within such models, the uptake of new research evidence can be represented by the activities of the rational mode of reasoning. For example, the decision to include a new treatment regimen based on a newly published evidence-based guideline for an individual patient is conscious, explicit and intentional. On the other hand, existing clinical practice can be positioned in the 'experiential' mode: well rehearsed judgements based on years of clinical experience may be viewed as unconscious, automatic, reflexive and swift. Changing practice, therefore, would require activation of the rational mode of reasoning to work in certain ways, as noted earlier [11]. In other words, changing an individual doctor's clinical practice (an experiential mode judgement) would require activation of their rational mode to consciously adjust or override that existing judgment. As well rehearsed judgments over time are thought to change from the rational to experiential mode of reasoning, it may be that more experienced clinicians are likely to be slower to change long-standing, often practiced judgments.
Despite acknowledging that medical decision-making occurs in a complex social environment with multiple influences and decision makers, it remains true that an individual doctor's judgement still retains a key position in terms of diagnostic and treatment decisions for individual patients. It is therefore relevant to consider how the individual dispositions of doctors may influence decision-making and clinical practice. As has been noted, it would actually be surprising if personality was not related to medical decision-making [15]. Whilst individual differences in personality are known to influence various aspects of patient encounters, such as communication and interpretation of patient behaviour, of importance to the current discussion are the particular aspects of personality which relate to thinking. That is, how doctors reason, and individual differences between doctors in reasoning are relevant considerations in discussions of medical decision-making.
Cognitive style may be another construct of interest as it appears at least conceptually similar to the need for cognition and faith in intuition. Cognitive style refers to the way in which an individual takes note of the surroundings, seeks meaning and becomes informed [25]. One popular measure of cognitive style is an individual's preferred modes of information-intake and decision-making, as measured by two of the polar preference scales of the Myers-Briggs Type Indicator (MBTI): sensing-intuiting (S-N), and thinking-feeling (T-F) [26]. The four possible preference types according to these scales (NT, NF, ST, and SF) have been associated with need for cognition [27], and it is therefore conceivable that they, too, may measure important individual differences in reasoning. Indeed, it has been noted that future research could usefully relate need for cognition and faith in intuition to the two dichotomies of the Myers-Briggs Type Indicator measuring cognitive style [28].
Considering such models of reasoning has several implications. First, if thinking dispositions are important, these need to be investigated further to determine their nature, how they vary between individuals, how they affect decision-making and clinical behaviour, and their interactions with other influences. Such other influences might include variables such as conditions of uncertainty. Relationships between thinking dispositions and clinical decision-making may initially be investigated theoretically using surrogate measures of clinical practice (e.g., clinical scenarios), although ultimately these relationships need to be demonstrated in actual practice.
Second, thinking dispositions may not only influence the direct process of clinical decision-making. In a broader sense, they may also influence receptivity to messages and different styles of message delivery. As an example, consider an evidence-based guideline within Cognitive-Experiential Self Theory. Reality is thought to be encoded in the experiential system in images, metaphors and narratives, as opposed to abstract symbols, words and numbers in the rational system [24]. If there are individual preferences for one mode over the other, then implementation strategies would best target both modes. For example, a guideline might be written to include both case studies (targeting the experiential system) and a full verbal and numerical exposition of the evidence (targeting the rational system). In terms of the implementation of such a guideline, it may be that use of opinion leaders to implement the guidelines might appeal to those who prefer the experiential system, whereas peer debate at conference meetings might appeal to those preferring the rational system. The direct implication is that implementation strategies need to utilise multi-faceted approaches in both the design of presenting evidence and the strategies to encourage uptake of that evidence.
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