Navigating the Decision Space: Shared Medical Decision Making as Distributed Cognition.

Despite increasing prominence, little is known about the cognitive processes underlying shared decision making. To investigate these processes, we conceptualize shared decision making as a form of distributed cognition. We introduce a Decision Space Model to identify physical and social influences on decision making. Using field observations and interviews, we demonstrate that patients and physicians in both acute and chronic care consider these influences when identifying the need for a decision, searching for decision parameters, making actionable decisions Based on the distribution of access to information and actions, we then identify four related patterns: physician dominated; physician-defined, patient-made; patient-defined, physician-made; and patient-dominated decisions. Results suggests that (a) decision making is necessarily distributed between physicians and patients, (b) differential access to information and action over time requires participants to transform a distributed task into a shared decision, and (c) adverse outcomes may result from failures to integrate physician and patient reasoning. Our analysis unifies disparate findings in the medical decision-making literature and has implications for improving care and medical training.

Portraits of patient cognition: how patients understand diabetes self-care.

Diabetes self-management is a complex dynamic process. Although patients are given guidelines for self-care, many still struggle with glucose control. This study uses techniques from naturalistic decision-making research to examine how patients with low, moderate, and good glycemic control conceptualize self-care. Eighteen people with type 2 diabetes were interviewed about their experiences with diabetes, understanding of the disease, and self-care behaviour. Qualitative methods were used to analyze responses and describe patterns of cognition. The authors describe participants' understanding of major areas of self-care and its relationship to self-management. The majority of participants failed to adequately understand the disease, typically because they were overwhelmed by or misunderstood rule-based instructions. Understanding of the dynamics underlying glucose regulation was found to be critical for effective self-management. Diabetes educators need to teach patients about the dynamics underlying self-management and to emphasize problem-solving and decision-making skills.

Everyday expertise: cognitive demands in diabetes selfmanagement.

OBJECTIVE: To assess the relationship between decision making and successful diabetes self-management. BACKGROUND: Patients with type II diabetes make routine but critical self-management decisions. METHOD: We conducted cognitive task analysis interviews with 18 patients to examine problem detection, functional relationships, problem-solving strategies, and types of knowledge used to make self-management decisions. We expected that these decision processes would be related to behavioral adherence and glycemic control. RESULTS: Verbal reports displaying problem detection skills, knowledge of functional relationships, and effective problem-solving strategies were all related to better adherence. Problem detection skill was linked to greater glycemic control. Participants differed in declarative and applied knowledge. CONCLUSION: Diabetes self-management draws on the same cognitive skills found in experts from diverse professional domains. Considering diabetes self-management as a form of expertise may support adherence. APPLICATION: Human factors approaches that support professional expertise may be useful for the decision making of patients with diabetes and other chronic diseases.