How Do you Make Decisions?

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How do you make decisions, not just in clinical work but in life? Do you ponder, obfuscate, data gather endlessly, look for hints or clues, match outcomes with risk benefit analysis or have a random set of parameters that are defined by mood and time?

Do you qualify decisions based on an abstract level of importance or keep a mental decision tree in your head that allows a structured approach that you have become reliant upon; are these processes knocked off course by emotion, stress and wellbeing or ultimately led by these?

What about clinical decisions? The ones that require some careful thought and analysis. After all, the process of clinical decision-making is the essence of everyday clinical practice. This process involves an interaction of application of clinical, biomedical, nutritional and lifestyle knowledge, problem-solving, weighing of probabilities and various outcomes, and balancing risk-benefit. A key task in this process is to balance your personal experience and prevalent knowledge.

Your clinical decision-making is the process of making an informed judgement about the treatment necessary for your patients/clients.  This process is complex involving several important steps in which patient/client involvement is essential. This is sometimes referred to as shared decision making (SDM) a collaborative process in which practitioners and patients/clients work together to select tests, treatments and health management or support packages, based on clinical evidence and their informed preferences and values. It explicitly acknowledges the fact that there is usually more than one way to treat a problem, including ‘no treatment’ and patients/clients may require help to weigh up the benefits and harms of the options in order to determine the best choice for them.

There is good evidence that SDM benefits patients, improving the quality and appropriateness of clinical decision making. A Cochrane Review of 115 randomised control trials found that use of patient decision aids leads to improved knowledge and more accurate risk perceptions among patients, greater participation in decision-making, and more appropriate treatment decisions.

Yet, to make these shared decisions, some level of knowledge beyond a vacuous series of conversational memes are needed, they are needed to anchor points for critical analysis. Yet information alone is not enough. You still require awareness of the overarching meaning of the information. Plus, it also necessitates separating the information which is relevant for a particular decision from that which is not. You have to add context to the variables. i.e. discard irrelevant information and figure out which facts are relevant for this precise situation.

Yet, the very flexibility of lifestyle intervention can make this process hard to apply, all the more so if the contextual knowledge base is embedded in strategies that are comfortable to the practitioner and yet incompatible to the client – how many times have you tried to mould a person to your preferred model, rather than listen, engage and share the journey? – it takes skill courage and confidence as well as experience to do this. Something that comes from application, and the process of action as well as recognition of emotive, intellectual, social and other barriers that may mean the decision is not a fully rational one. After all, your recommendations should be all about connecting with reality, not with a false version of events filtered through a lens of cognitive biases and shortcuts.

One of the criticisms by health care professional about Nutritional Therapists, health coaches and others is that their decision-making process is exactly that – one that is inextricably poor because their context is corrupted by biases promulgated by teachers and peers without adequate independence or critical determination of validity – for which the randomised controlled trial has become the pedestal upon which so much hubris is heaped by these enthusiastic public protectors.

Of course, there is validity in these comments, there are clear examples of poor decision making going on right now. You will have issued advise that in retrospect was wrong, inappropriate and without justification, or you may have used a protocol devised by someone for a named condition or conditions and felt worried and anxious when it either did not work or made the recipient feel worse. But be comforted, nobody makes perfect decisions, but some are clearly better at decision making than others, and in clinical care we should always strive to be better.

Whilst there is no hope of you ever being able to keep up with all the data that emerges on a daily basis, there is a deep responsibility to reflect, engage and explore changes and evolutions of interventional options, of the type you are trained to use. This can include peer to peer conversations, reading of papers or journals, attending CPD and CME events and of course using experience as a guide – however, one of the very first places to start is to recognise that you can’t just look at our own personal experiences or use the same mental recipes over and over again; we have all got to look at other disciplines and activities and relate or connect them to what we know from our experiences and the clinical world we live and work in.

To conclude – making decisions in lifestyle and nutrition needs a shared process of engagement, a willingness to review and disengage from historical patterns of application as knowledge evolves, a desire to be more open to critically analyse peers and their recommendations and yet retain a willingness to action something – after all, as with anything you practise if you do it right, the more you do it the better you will get.

As you begin to apply these processes you will recognise some fundamental changes to your thinking. In particular, you will become much more aware that your ‘beliefs are grayscale’. That is, despite your inner experience suggesting otherwise that they are not black and white and that you have for years held levels of confidence in your beliefs about how the world works that are less than 100 percent but greater than zero percent. This is a positive state of being as, even more importantly as you go through your clinical practice and encounter new ideas and new evidence, that level of confidence fluctuates, as you encounter evidence for and against your beliefs. Eventually a position of comfort that allows you to modify your opinions with objective information should evolve:

Initial Beliefs + Recent Objective Data = A New and Improved Belief.

… each time the system is recalculated, the application of care and SDM journey should become more secure in its application and outcomes more predictable.

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