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Thinking – situational awareness part 2

Author: Charlotte Davies / Editor: Liz Herrievan / Codes: CC4 CC5 / Published: 23/10/18

We make lots of decisions in our clinical practice, and it can be difficult to know how to make those decisions. We’ve talked before in the situational awareness blog about how the way we make our decisions can be contributed to by bias. We need to be aware of this potential so that we can prevent it happening.

Decision Making Structure

It can be useful to have a structure to our decision making whilst also being aware of how we think. When making decisions, especially under a pressurized system, using a structure can be really useful to make sure you avoid bias, and consider everything.
“FOR DEC” can be a useful tool – like many human factors tools, this stems from aviation.

F – for FACTS = “what is the problem?”

It seems silly, but sometimes we are trying to solve the wrong problem. Often, the problem is not “what is making the patient unwell” but “what can we do to make them better”. Or the cynics might say, not “what’s wrong” but “which specialty do they need admitting under”.

O – for OPTIONS “what different options do we have?”

Even in a time pressured situation, it is useful to consider our options and make sure we have thought about all of them. Your different levels of situational awareness will have given you a list of options already. Talk to your team, and share the mental model whilst doing this. Some people like to list all of the options and some people like to find the best solution. These are the convergent and divergent thinking styles we mentioned above.

R – for RISKS and benefits

Sometimes there will be lots of risks, and no benefits. Sometimes there will be benefits to all of your options. EM Updates talks about balancing the risks to create the “preferred risk” – really useful to consider, especially in the unusual cases.

D – for DECISION

The old wives tale says that any decision is better than no decision. Tell the team what decision you have made!

E – for EXECUTION – “who will do what and when”

This is an excellent time to practice your closed loop communication, and tell named members of staff what needs to be done. It’s important to use specific names – we’ve all heard the story of somebody, anybody and nobody!

C – for CHECK – “did it work”?

Check this in a reasonable time scale.

FORDEC can be a useful way to structure our decision making. Most of the time, we make decisions without using a decision making tool, and we are unaware of our decision making process. Yet sometimes, we are aware of how we make decisions.
There are theories about how we make our decisions, and the most popular one is the “thinking fast and thinking slow” theory.

Thinking fast and thinking slow

Type One thinking – or thinking fast – is pattern recognition. This is often related to unconscious competence, and experts who do this frequently can’t explain their thought process. Type one thinking is an automatic, or subconscious process. It’s fast and effortless but it’s also inflexible. The easiest example of this is driving home – you’re doing well…subconsciously driving, then bing…there’s a diversion, so you flip to type two.

Type Two – or thinking slowly – is balancing everything, and summerising all the facts. Arguably, this is the safer option – but it takes a lot longer. If mistakes are made though, they are assessed and reviewed by type two thinking! This is a conscious processes, and you know if you’re thinking in type two because you can feel all of your brain making that decision, and thinking hard. It’s slow and effortful, using working memory.

The wonder of whatever type of system we use, is that we “self check” and flit between system 1 and 2, thinking fast and thinking slow, to make sure that we’re thinking properly.

Daniel Kahneman: Thinking fast and slow @RIGB

Convergent or Divergent Thinking

There are generally two ways we make decisions – thinking fast or thinking slow or convergent or divergent thinking. Those who think divergently out number convergers 3 or 4 to 1 in arts subjects like history, english literature and modern languages, with equal divergers and convergers in biology, geography, economics. Convergers outnumber divergers: 3 or 4 to 1 in physical sciences – mathematics, physics, chemistry, classics, so I suspect medicine probably has a fairly equal number of convergers and divergers.

Divergent Thinking is the ability to find as many possible answers as possible to a particular problem. Thinkers like ambiguity, and a range of possibilities and options. They’re creative and experimental.
Convergent thinking is the ability to find the optimum single answer to a problem – the tidy “correct” answer, clear logical progressions, with logic. If you cook convergently, you follow the recipie exactly.

These are really similar to thinking fast and thinking slow – type one or type two thinking.

Bias

There are lots of different biases in existence, and it is easy to become biased, especially if you are “thinking fast”. There’s a lovely example here that is aimed at primary care – but could easily be relevant to us.

If you can think of a mistake you’ve made, there’s probably a descriptive bias for it. There isn’t really an easy way you can stop yourself from being biased – have a look at this series of posts for more details on bias. Take a pause, run through everything again, and try and use a bit of system two thinking. Biases are of course more likely because we are constantly pushing our legal boundaries – maybe as a start, think about whether you’re pushing the boundaries too much. If you are…error is more likely.

The picture above looks familiar to many of us. But what if we replace the amber zone with “looking after 10 patients instead of 4”. Or “making hasty decisions”. It’s all too easy for us to then slip in to the danger zone.

Prioritisation

Sometimes you have lots of things to think about, and have to prioritise which to think about first. Experience will help you here – there’s a few tips in our time management blog. Have a look at the article, and then mentally rehearse how you would prioritise the management of a post-partum haemorrhage? Or a cardiac arrest. Occasionally your priorities are not the same as the patient’s priorities which are not always the same as priorities of other members of the team. Share the mental model with everyone.

Distractions

Distractions and interruptions are a really important part of your thinking process. We’ve written about how to deal with them in the EMJ supplement. We could reprint them here, but that would be counterproductive – have a read and add your comments below.

We hope that’s been a useful introduction to some of the ways in which we think, and how to think better. This blog tickles the surface of a really interesting and complex subject – please add your suggestions, and links below on the twitter comments!

Further Suggested Reading

RCEM Learning Blog – Situational Awareness
RCEM Learning Blog – Time Management
EMJ Supplement – Dealing with distractions

St Emlyns – good decisions
EM Cases – Decision Making
Emergencypedia

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