Veterinary work is full of decision making. A typical shift is filled with quick-fire decisions involving patients, sometimes with complex complaints and multiple stakeholders. What is the best way of juggling our clinical appraisal of the patient and existing evidence, while taking into account owner preference and limitations of finance, availability and even palatability of various options?
According to behavioural economist Daniel Kahneman, decisions can broadly be split into two categories: fast and slow. Fast decisions are instinctive and emotional (sometimes hot-headed!), with little effort and no sense of voluntary control. Decisions are often made based on unconscious bias, such as doing something because it worked last time, or dealing with a complaint happening in the waiting room. The slow system is deliberative and logical, allocating attention and time to evaluate variables and evidence, and make reasoned choices. This is more typical of patient work-ups, or the interview process for a new member of staff (cool, calm and collected).
Decision making will also be affected by pre-existing bias (whether conscious or unconscious). Bias can be a powerful ally when it guides us to quick-thinking problem solving. However, we have to be aware of its existence to check we’re making the best decisions.
Disappointingly, yet unsurprisingly, a research collaboration between the BVA and the University of Exeter showed gender bias is present within the veterinary profession. Employers were more likely to rate male candidates as better qualified and give them a higher salary than the female candidate. They were also found to be willing to invest more in the development of the male candidate.
How do we go about making the best decisions for our patients, staff and practices? The first key point is awareness of bias. The BVA study showed that gender bias is largely mitigated where it is perceived. Simply being aware of our inherent bias means we are able to address it. This relates to self-awareness and the ability to recognise our cognitive blind spots, whether others can see them or not.
Take your time and consider issues properly. There are many models for effective decision making: variations on a decision tree. These are great in principle, but who has time to implement them? Creating space to critically appraise clinical information is important, such as case reviews with colleagues. Decisions about a course of diagnostics or treatment for a pet are a shared decision with the owners, who will bring their own bias and their own resource limits of time, finance, health, circumstance and emotions. Sally Everitt’s PhD found decision making in veterinary practice is more a negotiated activity in comparison to human med-cine, taking into account the animals’ and owners’ circumstances as well as biomedical information. Recent research has shown the shift in communication style between vets and clients from paternalistic to partnership.
Justifying decisions with evidence and recording our reasoning helps to address bias. Herein lies the value of CPD and case reviews with colleagues to build a solid evidence base as well as transparent and open employment practices. Our decisions are only as good as the information we have; more reliable facts reduce uncertainty. However, there is no such thing as “perfect” knowledge and endless evaluation can result in “analysis paralysis”, where we become indecisive and, consequently, ineffective.
Broadening our experience base, whether this is trying a new procedure or conversing with a wider diversity of people, challenges your status quo. Tiredness, stress and time pressure can lead to poor decision making and increased risk taking. A 2018 review by Baumister et al. noted the negative effects of these factors on the decision making of children in academic settings, hospital staff, judges and voters. Research by Kirchler et al. showed individuals are more likely to make risky choices under time pressure.
In the workplace, policies and procedures can be implemented to reduce the influence of individuals. This is where decision-making models are useful tools to guide processes and mitigate the influence of bias, for example during the interview process. Simple steps such as requesting CVs to be submitted where the gender is not revealed has been shown to reach more equal outcomes and reduce bias in shortlisting candidates.
There is no such thing as the perfect decision; even with our best efforts factors outside our control may thwart our efforts. There is a fine balance to strike with critical appraisal of available choices, versus time constraints and personal resources. The principles of being aware of and addressing bias, evidence gathering, effective communication, and appraisal and review of the decision-making process will help us to make the best decisions with the tools we have. Despite our perfectionist tendencies, a good decision is good enough.