Decision Science Roles in Medical Decision Making

Medical decisions are difficult for several reasons:

·         They involve multiple objectives, such as alleviating pain and suffering, quality of life, long term health impacts, cost, and so on.  

·         They involve numerous participants:  the patient, doctors, insurance companies, family, employers, and yes, even the government.  

·         More and more data (both good and not so good), is becoming available.  What information is more reliable and what treatments do the more reliable information support?

The question of who makes a medical decision is paramount.  Ideally, for most of us, it would be the patient, and ideally it would be a decision to select that alternative which best satisfies the patients objectives.  (A decreasing minority of people would like nothing to do making with the decision but just leave it up to the doctor).  Determining which alternative is ‘best’ is usually difficult because it requires a synthesis of tradeoffs among conflicting objectives, interpretation of opinions of more than one physician, and an understanding of the complex and often competing data and research results. 

Common practice today consists of a series of medical examinations, tests, and consultations, followed by a haphazard search for additional information.  The patient is often left weighing pros and cons that result from physician recommendations that are: conflicting, biased (naturally so since each understands their specialty best) , and constrained by cost/insurance considerations.  The patient must make a gut feeling choice after sleeping on an overload of information.  Moreover, the decision alternatives may be limited to a set of alternatives that have been pared down because of what some bureaucrat (does it matter if the bureaucrat works at an insurance company or the government?) has decided.

Newer techniques for helping patients decide are evolving.  These typically involve a more systematic way of gather information and presenting it to the patient (see “Weighty Choices, in Patients’ Hands”, Wall Street Journal, Aug 4, 2009 <http://online.wsj.com/article/SB10001424052970203674704574328570637446770.html>.  

However, even if the patient has the latest and best information, the decision is not likely to be one that best meets the patients objectives for at least two reasons.

First, and perhaps at the center of today’s debate on health care, is that patient  alternative choices need to be broadened by reducing restrictions imposed by insurance companies, government, and the ability to pay.  Vested interests are making it difficult to change from what is obviously a poorly functioning system where a patient is rarely even aware of the cost of alternative treatments, and  is sometimes even prevented from choosing  specific alternatives  which are deemed inappropriate by a third party.   Decision science has much too offer in this debate, but has contributed little thus far.

Second, in order for patients to make decisions that best meet their objectives, they must be able to synthesize data and information (much of which is very technical), physician opinions (sometimes from physicians in different fields, each only superciliously knowledgeable about fields outside their own), and most importantly, their own objectives (which are often conflicting).  

Medical decisions, are, by their very nature, subjective.  This is because the relative importance of the patients objectives differ from patient to patient.  But subjective doesn’t mean casual, sloppy, or inconsequential . Subjective simply means that the decision will differ from patient to patient.  There is, in fact, a single best choice for each patient.  Theoretically sound and practical techniques in the decision sciences, such as the Analytic Hierarchy Process,  have been shown to be able to help patients determine the alternative treatment best suited to their individual circumstances and objectives. (A Novel Computer Based Expert Decision-Making Model for Prostate Cancer Disease Management”, Journal of Urology 2005 Dec; 174(6) 2310-2318) http://linkinghub.elsevier.com/retrieve/pii/S0022534705009626.  Not only can such techniques help patients make decisions that best meet their objectives,  reassure patients that they are making the ‘best’ decision for them, are convincing to attending professionals and third parties who may be footing part or all of the bill, but the decisions can actually be less costly to the patient, insurance companies and the government alike.  The use of such techniques is likely to become widespread in the not to distant future.

Kudos to OMB and Federal agencies for completing the ratings of 100% of their major IT investments, which by the way was no small undertaking .  So we now have a complete and well presented view via the Federal IT Dashboard (http://it.usaspending.gov/) of how well our “major” Federal IT investments are adhering to cost, schedule and various risk (via the Evaluation Factors) metrics.  Assuming the data is and remains accurate and current (and sure, why not , we have a pretty good picture of the Investment side of the ROI equation.  

As OMB seeks to continually improve reporting via the IT Dashboard and facilitate effective management of our Federal IT systems, I’m hopeful that OMB’s next step will be to focus on the Return side of the equation.  After all, we don’t create and manage projects simply to have them completed on time and budget.  While some investments are still under initial development and thus have not yet had the opportunity to produce a return, many of the “majors” are in the Operations and Maintenance phase where they should be delivering value (return) to their end users.    

Measuring return, especially in the Federal government where not all benefits can be monetized, can be difficult, but there are ways that this can be achieved.  For starters, a simple measure of customer satisfaction might be an informative addition to the Federal IT Dashboard.  

The Total Perspective Vortex is a wonderful thought experiment. It’s also perhaps an important reminder as us in the western part of the world fret over the economic news that is following on the heels of the implosion of the credit markets.  Many are likening the situation to the Great Depression.  That’s as you say hyperbole of the worst kind-at least in the USA.  Sure things are bad an may get much worse still.  But here is a list of things that are unlikely to happen even in the case of a lengthy an deep recession:

A third of the population will not be ill clad, ill nourished, or without a roof over their head.  Prior to the Great Depression there was barely enough housing to house all the people in the country, and barely enough food, or clothing either.  Now we have a ridiculous excess of all three.

Unemployment, even if it were to reach levels of 15% would have much less impact than in the 1930s.  Most people would receive up to 13 months of government unemployment assistance.  The elderly would receive health care, the young would still be fed at school.  No panacea, mind you, but no depression.

I feel for all those who have and will lose their income and homes in these tough economic times.  But let us not give in to the scaremongering of the media, who jerk at our emotions, frighten us with fearytales, and peddle their poornography.  This country, or the western world for that matter, is not about to become some Mad Max movie set.  Unless of course we all want to believe it, in which case I’m sure we could achieve it.

We had a little ‘incident’ in the office this week.  It really started a few weeks ago when we got a super cool automatic espresso coffee maker.  It’s the kind that you just walk up to it and select the shot size, press a button and voila out comes wonderful coffee.  This all worked very well until someone put ground coffee instead of whole coffee beans into the bean container.  The machine clogged up and was ‘rendered inoperable’ as they say. No one came forward and claimed responsibility (probably a smart move if you consider the state my coworkers were in, what with the lack of coffee and all).

So, I had a couple of problems: first where to get some coffee (it’s like a 10 minute walk to the nearest Starbucks), and second how to figure out who did this and why they didn’t take responsibility (the third problem, how to fix the machine was thankfully solved since then, as one of us is a former coffee barista and she fixed the darned thing).

And then I remembered something about framing.  Not people, but problems.  And if the problem is to get people to do something they don’t want to, it’s the Tom Sawyer version of a framing problem.  Normally, when you want to learn something you ask.  So, I could go around asking people if they had put regular grounds into the espresso maker, and broken it.  This would make everyone rather upset that I was accusing them of a) not knowing what they were doing, and b) not owning up to it.

So, I could easily frame this in a way that the only person who would feel upset, was the person who actually broke the machine.  You see, it’s just about how I ask the question.  If I asked everyone who had opportunity a simple question: “I just wanted to ask everyone to confirm that they didn’t break the coffee machine.  Please respond by saying: I did not.”

Now the smart ones reading this will say that the culprit either a) will not answer, or b) simply lie.  Let’s explore that.  If you don’t answer, then I’ll remind you to answer.  Those who have nothing to hide will ultimately answer. Those who have something to hide will be reluctant to, but if only one person remains then I know who to confront.   Now, the lying scenario is if everyone says they didn’t do it, then I know that someone didn’t just ‘forget’ to tell about it, but actually and actively lied about it.  I won’t like that, but I will have learned something very important: a dishonest person is working for me, and probably a stupid one too.  Because if I put energy into it, I can probably figure out roughly when the machine broke, and thus narrow my list.

But, in the end, the framing exercise makes it a lot more likely that I’ll get the result that I want.  But logically the two approaches are equivalent. One is just a more effective way to elicit information from humans–even if the information gained is the same.

Of course, there is a third way of framing the problem: blogging about it, and letting everyone in the office know, and hoping the poor sop comes forward.

Welcome to Decision World.

 Decision World has a simple goal: to become the Internet gathering place where people can share their insights and thoughts on decisions.  We plan to have space for academic thinking, as well as corporate practices, and government experiences.  Our hope is to find young people making their first important personal and professional decisions, and people who, if no longer young, are still finding new challenges and opportunities in their lives.

Decisions happen.  Some are good, some are bad.  Our hope is that a meeting place like Decision World can make the decisions that happen a little better.

andri
…

With this blog, Andri and I (along with many to come) hope to explore real-life and theoretical concepts in decision-making and collaboration. Andri and I have had some very interesting conversations, and we came to the conclusion that we should take these conversations to the blogosphere. We hope to build a conversation about how we make personal decisions regarding things like careers and college, as well as decisions and collaboration within the enterprise. What tools can be used? What processes work best? What pitfalls exist that lead to bad decisions?

Andri’s an expert in decision-making. I’m not. I hope that this signals where we want DecisionWorld to go. We’ll be adding regular and guest contributors, and we aim to strike the right balance of academic and layman, theoretical and practical. I’m involved in leading a new web start-up, and there’s lots of decisions to be made. If you think about it, making decisions is the most important role of an executive, and often the most difficult or mystifying. This holds true in life as well.

Onward!