Today, I have my buddy and innovator, Andrew Petrosoniak to talk about making good decisions, a crucial skill in the resuscitative specialties.
Andrew Petrosoniak
Andrew Petrosoniak, MD, MSc (MedEd), FRCPC is an
Emergency Physician & Trauma Team Leader, Lead, Translational Simulation & Clinical Integration at St. Michael's Hospital, an Assistant Professor at the University of Toronto, an Associate Scientist at the Li Ka Shing Knowledge Institute and Co-Principal, Advanced Performance Healthcare Design. Find him on the web at: advancedperformance.ca or on the hellhole that is twitter at @petrosoniak.
1. Reduce decisions whenever possible
Design your system so that decisions don’t need to be made in the moment.
Ever try to eat healthy? It’s far easier at the beginning of the day than the end. Rather than rely on will power, ensure your environment supports your goals…
In medicine, use clinical decision rules, or decide a-priori–how you’re going to proceed before you’re faced with the situation. Create rules around frequent decisions.
E.g. for blunt traumatic cardiac arrest I don’t routinely proceed with an thoracotomy…except under rare circumstances which I check for. Or for high velocity trauma, I always do a CT-A carotids…based on my lit review done before faced with the patient in front of me
2. Sign-post decision points
Set explicit parameters or targets to trigger an action.
E.g. “at 80% we’ll halt attempts at intubation and re-oxygenate the patient.”
This reduces emotion that can be tied to making decisions under stress. Plus promotes accountability
3. Deliberately consider alternatives options
This is one of the biggest decision making pitfalls. We often fail to consider alternatives. Using the heuristic “is there any other option” even after you’ve listed a few forces creativity and may illuminate viable alternatives. After creating a differential diagnosis for chest pain, ask “is there anything else this could be”? Getting in this habit will result in new options come to light
4. Assign probabilities to decisions
Virtually no outcome is certain. Its not enough to say “its likely” or “its unlikely” since we naturally assume this means it IS or it ISN’T. By assigning a numeric probability this conveys uncertainty & forces coming up with alternative
consideration of alternatives. If there’s 80% chance the patient has appendicitis, by definition there’s 20% chance it’s something else
5. Learn from decisions
Use a decision making journal. This forces deliberate reflection on your state of mind and how your expectation/prediction matched the outcome. This promotes learning and hopefully improved decision making over time.
Review probabilities too…if you ALWAYS predict something to occur at 90% and it NEVER happens, its time to re-evaluate your predictions.
- A great read on decision journals from Farnam Street
- Sample Decision Journal
And remember, you need the results of your decisions before you can judge them, so get follow-up!
6. Use one line summaries
Sometimes we get bogged down in the details. Simplifying a situation with only the most pertinent information can make a decision easier while eliminating extraneous information
7. Use a pre-mortem
Assume your decision or project has failed and come up with all the reasons why. Knowing these ahead of time can allow you to put into place mitigation strategies.
E.g. my next intubation results in being unable to secure the airway…why? What led to this situation or a failed attempt? And what steps can I take to manage this.
8. Debrief decisions
Debrief either individually or as a team. Context should be focused on the decision making process not just the outcome. Both good outcomes & poor outcomes are worth reviewing b/c sometimes good outcomes still result from bad decisions (& vice versa)
More Stuff
- A short commentary on probabilities in emergency medicine.
- A nice short read referencing some work by Annie Duke on decision making
- EMCrit Lecture on Decision-Making, Resus Wankers
Get Your CME for this Episode
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Now on to the Podcast
- EMCrit 378 – So NSTI – Necrotizing Fasciitis & Life Threatening Soft Tissue Infections - June 29, 2024
- EMCrit Wee – Adaptive Support Ventilation (ASV) - June 24, 2024
- EMCrit RACC-Lit Review for June 2024 - June 18, 2024
Great talk and reflections ! I would love to hear your thoughts about how to best teach learners about those decision making strategies.
Used 2&4 with a cardiologist yesterday to perfection! Thx so much for the instantly useful advice
Where can I get your book? Some call it catastrophic thinking, I call it prudent planning. Its all based on decisions and the process of decisions, the various biases than can trap us etc
Its on amazon!
Very refreshing thought content! Our shop has become more resistant to proactive thinking. This trickles down into the fabric of the ER. We’re still doing alright, and will do our best to incorporate a lot (if not all!) of the tips you listed today, but how do we encourage our leadership to make more of an effort to anticipate issues? A perfect example is talking to our surgical colleagues and convincing them to scope a patient. Unfortunately, they often ignore the evidence, and sometimes that’s used as an excuse to the point that you have various approaches to the same… Read more »
I Love the thoughts, thank you for sharing