Decisions, decisions, decisions

Carmen Wong

HK Pract 2020;42:49-50

As Hong Kong grapples with the third wave of COVID-19, each week brings difficult decisions and new measures from health care quarantine on inbound travellers, to widening testing to health care workers and the community and policies such as the use of facemask in indoor and outdoor public places, limitations of restaurant capacity and opening hours, etc. Each decision is multifaceted and requires careful consideration of the public health, hospital capacity and community behaviour and sentiment. The speed of response has been key to combat the spread of disease.

Similarly, our patient consultations also require us to make difficult decisions and quick responses in an age of constantly evolving medical information updates. The progress over the past few decades has been revolutionary in terms of access to medical information. Bygone are the days of sifting through numerous piles of medical journals at our offices and desks. The ease of digital peer reviewed databases provide information at our fingertips almost instantly. However, clinical decisions remain fraught with uncertainty and risk.

The term “Iatrogenic” has Greek origins with “Iatro” meaning doctor or healer and “gennan” meaning as a result thus iatrogenic describes the results of a doctor, e.g. by diagnosis and treatment. The case study of bilateral leg oedema by Siu et al ¹ draws our attention to the possibility of iatrogenic disease caused by common drugs we prescribe every day.

Understanding of decision-making processes and common errors can help make better clinical decisions and minimise iatrogenic events. Despite evidence and clinical guidance, there are often gaps between evidence and practice which require physicians to make individual decisions based on their known (and often limited) amount of information. There are two main processes in making decisions. ² System 1 is the process of rapid intuitive decisions whilst System 2 is an intentional analytical approach which require further location of deeper information than that not obtainable by instant recall. As System 1 requires less effort, this system is frequently used subconsciously. Errors in decision making may occur when doctors rely on System 1 which is prone to cognitive biases and emotions. Activation of a System 2 allows checking and researching of the best available evidence. Interventions to encourage appropriate use of System 1 and System 2 processing have been shown to improve clinical decision making and are largely clinical decision tools made for clinicians, e.g. computerised clinical decision support system – such as drug interaction alerts, clinical information prompts on clinical systems. Meanwhile, physicians nowadays are rarely a one-man operation, iatrogenic events can extend to the clinic or hospital in which doctors operate and not only lead to physical sequalae and death but can also cause mental or emotional sequelae. Reducing iatrogenic events requires constant oversight of hospital and clinic procedures, protocols and significant event analysis, professional training and development of staff as well communication with patients and family to enhance understanding of medical diagnoses and treatment.

Dr. Tsim ³ highlights the importance of staying up to date with evidence for medical professionals and taking a holistic approach to bone health and importance of patient communication in an update review of osteoporosis. The importance of communicating to patients about the risk of osteopenia and osteoporosis and advising patients on management are highlighted , along with a detailed guidance of calcium and appropriate exercises at different life stages can be helpful for us to tackle the practical questions that patients often have. Increasingly from consent of operations to management of medical conditions, a shared-decision tool can help clinicians reach a decision that encompass doctor’s advice and patient preference. Shared decision tools can also be particularly useful when the evidence is not certain, where no one option is superior or when benefits and harms need to negotiated along with patient preference and clinician experience and health care contexts. Such tools can take the form of patient decision aids, option grids, evidence summaries or more general communication frameworks ⁴.

Over the past few months during COVID-19, we have witnessed different countries introducing restrictions in social activities to reduce the transmission of infection. These measures range from closure of leisure facilities and beaches , physical distancing, lockdowns and social bubbles. Consequently, the public have been more aware of the ill effects of these measures on their own mental health and of others. In recent years, the evidence base for mindfulness in the treatment of depression and anxiety has strengthened. Lee and Wong ⁵ provide a timely review of mindfulness meditations and the evidence base for the treatment of mental and physical conditions. The detailed example of a programme of Mindfulness Based Cognitive Therapy (MBCT) can be helpful for family physicians to assess whether mindfulness may be suitable for their patients and to explain to patients what mindfulness involves. Just as school and work are adapting to online modalities, mobile apps for mindfulness can also be a handy way to try and practice mindfulness meditations. Meanwhile, family physicians are at risk of burnout especially in the current heightened state of alert of COVID -19 but this can also be an opportune moment to try these interventions for ourselves. Attention to our emotions as well as cognitive biases in our decision making processes can make us all make better clinical decisions.