Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors.

PURPOSE: To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN: We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS: We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS: Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

Health Education and Activity - Lessening The Inequalities in mental health (HEA - LTI mental health).

Patients suffering from mental health illness have considerably more physical health disease burden than the rest of the population and are more likely to die 10 to 20 years younger compared with their peers. Diabetes, cardiovascular and respiratory disease have been recognised as contributing factors to premature death. Furthermore patients with severe mental illness undertake lower levels of physical activity. The aim of the project was therefore to address the inequalities in physical health that affect patients with mental health illness through designing and implementing a sustainable, transferable, patient-centred education and activity intervention. The objective of the project was to increase patient motivation to change behaviour as a result of physical health interventions by increasing patients' physical health understanding, motivation to change their physical health behaviour, motivation to do exercise and by reducing their anxiety. The method used was a prospective cohort study in four eighteen bed psychosis inpatient units. The units were across two large London hospitals in one Hospital Trust involving male and female inpatients with a range of mental health issues. The intervention was comprised of two components. The first component was a weekly 45 minute teaching group designed in collaboration with patients focusing on the key domains that affect the physical health of mental health patients. Four discussion domains (heart health, diabetes and weight, smoking and lung disease, cancer screening and substance misuse) were undertaken, with each cycle lasting four weeks. The second component was a weekly 45 minute exercise group ('normalisation activity') in collaboration with patients and the multidisciplinary team. The intervention was evaluated at the end of each cycle and four cycles in total took place. Weekly pre and post intervention measures were undertaken comprising of a self reported change in understanding, motivation to change physical health behaviours, confidence to change, anxiety and motivation to exercise. The result was a 26% improvement in self-reported understanding across the four domains following teaching. Furthermore patient anxiety reduced by on average 35%, self-reported motivation to change increased by 20%, motivation to do exercise by 26% and confidence to change by 16% as a result of the intervention. The authors conclude that a collaborative approach to education and activity between the Multidisciplinary Team (MDT) and service user results in sustained improvement in understanding of physical health, motivation to change behaviour and to do exercise. It also results in improved confidence and reduced anxiety.