Friday, November 02, 2012

Naturalistic Decision Making,phronesis and the making of an expert

A recent blog posting by Dr Robert Centor, see here, introduced me to the term "naturalistic decision making" which seems to be one aspect of the broader area of the study of cognitive reasoning, or how we make decisions. In this regard one focus is on decisions in which there are high stakes, time pressure and complex situations as is common in emergent clinical situations.

Basically  faced with that type of situation,such as the challenging chest pain case  described in Dr. Centor's article, expert clinicians typically rapidly categorize the situation based on a pattern recognition ( as described by Kahneman as a System 1,fast and unconscious mental act) and then move on to use a deliberate,analytic System 2 approach involving,in part,  a search for missing data and for discrepancies and then a simulation of what might occur next if the first plan based on the first impression were carried out.

The Nobel prize winning work of Kahneman and others working to elucidate how people think in have apparently fleshed out possible mechanisms of  some of what Aristotle referred to as  Phronesis.

Aristotle spoke of the virtues of the  mind as including:

sophia (wisdom of first principles),
episteme (emperical knowledge,
techne (technical knowledge)
nous (intuition) and
phronesis (practical wisdom or prudence).

Evidence based medicine  with its emphatic focus on  techne and episteme may foster the illusion that good clinical practice can be encapsulated in guidelines and pathways and that quality lies in obedience to them but it is the blending of those elements of science and technique with practical wisdom that makes good practice. Treatment guidelines or algorithms come into play only after a diagnosis has been reached and in all but the most trivial cases a bit of phronesis might help.

 In Kathryn Montgomery's 2006 book, How Doctors Think, we find the following quote which sounds a lot like what we learn from the field of Naturalistic decision making:

"Clinical judgment done well is the intuitive and iterative negotiation of the patient's narrative of illness...This focus come with experience"

And for that I don't believe there is an algorithm.


1 comment:

Michel Accad said...

Good, James, thanks! "Naturalistic decision-making" like all new ideas, was discovered 2500 years ago! :)

I agree with you, phronesis seem to be the right idea for what doctors should be doing. As you know, it was part of Aristotle's Ethics, and was to also be a way to achieve the common good.

As you allude to, our modern medical ethics expert want us to help both the patient and society with a combination of techne and episteme. How imprudent!