“He who can modify his tactics in relation to his opponent and thereby succeed in winning, may be called a heaven-born captain.” – Sun Tzu, The Art of War
The quality of healthcare is a function of the quality of decisions made by patients, practitioners, and policy makers.
Recent advances in healthcare have led to multiple alternative management strategies becoming increasingly available for many problems. In the absence of a single dominant strategy, choosing a preferred management option depends on preference-driven tradeoffs between their respective advantages and disadvantages. Because patients are the ones who will be most affected by the outcomes that follow, current ethical and moral care guidelines emphasize the importance of making clinical decisions using a process of shared decision making that makes patient preferences a key decision making consideration.
Despite a clear moral imperative to engage patients in decisions about their healthcare, routine shared decision making has been difficult to incorporate into clinical practice. In a 2017 paper, Elwyn and colleagues identified several factors impeding the uptake of shared decision making including failure by many clinicians to recognize the need for a new clinical decision making approach. [1]
One thing that could help both clinicians and patients better understand why changes in the conventional practice of clinical decision making are needed is a deeper understanding of the complexity of the decisions they face. The Cynefin framework, developed in 1999 by David Snowden is well suited for this task. [2]
Cynefin is a Welsh word meaning habitat. The basic idea is to give decision makers a framework for understanding the “lay of the land”, that is, the level of complexity posed by a decision to enable them to adjust their decision making process so that it is appropriate for the context.
The Cynefin framework describes five decision making scenarios: clear, complicated, complex, chaotic, and confusion. It is typically described using a diagram like this one: [3]
Decision making in the clear domain is relatively simple. Cause and effect relationships and known and predictable. Consequently there is one choice that is best in the vast majority of circumstances.
In the complicated domain, instead of a single clear cut choice, several acceptable choices exist. Much is known about the options and their likely outcomes can be accurately forecast. Choosing one option over the others therefore depends on tradeoffs between the relative advantages and disadvantages of the available options.
The complex domain is similar to the complicated domain except the outcomes of decisions are uncertain. Therefore, the decision-related tradeoffs need to be made in a way that takes into account the uncertainty about the outcomes that could follow each option.
In the chaotic domain, little knowledge available to guide decisions. Decisions in this domain need to be made on a trial and error basis.
Finally, the confusion domain is for situations where it is unclear which of the other domains applies.
Many routine healthcare decisions fall into the clear domain. A simple example is that one should seek immediate medical attention for acute onset of crushing chest pain and shortness of breath. Because the relationships are well known, the clear domain is an ideal place for simple guidelines and algorithms.
In situations that fall into the complicated and complex domains, additional information and analysis is required. It is in these domains that patient input provides information vital to effectively manage the added complexity of the decision making situation.
Musings
Understanding the level of complexity involved in a medical decision and knowing how to respond appropriately is the hallmark of a good practitioner.
References
Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, et al. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.
Snowden DJ, Boone ME. A leader's framework for decision making. Harvard business review. 2007 Nov 1;85(11):68.
Cynefin Framework. https://en.wikipedia.org/wiki/Cynefin_framework
By Tom@thomasbcox.com - Own work - a re-drawing of the prior artwork found here (https://commons.wikimedia.org/wiki/File:Cynefin_as_of_1st_June_2014.png) that incorporates more recent changes, such as renaming "Simple" to "Clear"., CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=123271932