How Decisions are Made

Elena Rocca, Thinking about guidelines:

I was interested in a question that Sietse threw at us many times: what should be the purpose of a guideline? What does “helping to make a good decision” mean?

We got some inputs about it throughout the whole day: it might mean including the patient view, or reporting only the evidence with no recommendation, or giving recommendation but being transparent about which evidence was considered and how it was judged, or again, as Sietse suggested, it might mean to explain what is “to make an inference”, what happens when a clinical decision is made. I was particularly interested in this last suggestion, and I felt it remained a bit “in the air”. Does it mean that we would need a guideline about the decision process? About the implicit and sometimes unaware stand that the clinician takes by valuing one or the other evidence, following the guideline versus personal judgement?

Real v Ideal Guidelines

Rani Lill Anjum, Thinking about guidelines:

I was really interested in the questions of how guidelines could include more leeway for the health professional. Rigid guidelines offering cost efficient solutions (e.g. 15 minutes per patient, or 30) emphasises the rule utilitarian approach and makes it difficult to use judgement and experience to give the best health service for the individual patient. If the patient represents at least as much of the causally relevant evidence (medical history, genetics, life situation, etc.) as population data, then how come the latter is given epistemic priority?

I thought that there were many good intentions behind the guidelines, but also a wide range of interests depending on who commissioned the guideline and what they want to use it for. This is why I thought the tension between real and ideal is important. New public management emphasises top down management, controlling, reporting, standardisation and efficiency. In the clinical setting, this approach might create chronic illness, if we simply treat or test the symptoms that the patient reports. Those who work on the importance of patient context and stories (Trish, Matt, Brian, Anna-Luise) have important knowledge to share, and show also that the most efficient treatment of such illness is to take more time with the patient to figure out what is actually wrong before offering an intervention or a test. Why could this not be in guidelines about chronic illness, MUS and comorbidity? Then we would also avoid reductionism and dualism of treatment.