How do experienced clinicians see beyond the superficial and understand the trouble brewing behind the scenes, seemingly before there is any warning? Where does such an unearthly prescience of what is about to happen come from? How is it that one sees what another doesn’t?
Being an expert clinician is not just a matter of making the right decisions, it is a matter of knowing when there is a decision to be made. This process is called ‘sense-making’.Sense-making is a meaning making process in which people faced with ambiguity or uncertainty “organize to make sense of equivocal inputs and enact this sense back into the world to make that world more orderly”.Sense-making is about asking and answering the following two questions: “What is the story here?” and “Now, what do I do?”
Although sense-making and decision-making are often lumped together sense-making precedes decision-making. When action is the central focus, interpretation not choice is the core phenomenon.- from Croskerry P, et al. (2009)
When I trained as a doctor I was taught to view diagnostic and management decisions as a choice between a series of alternatives. But the ‘sense-making’ step was largely ignored – in reality, before such a ‘choice’ can be made, we must realise that such a choice needs to be made. Achieving this is particularly challenging in the chaotic environment of the emergency department, where patient encounters may be so confusing that we are not even sure why they have presented, and both time and information are scarce resources.
So, how can we create order on the edge of this chaos?
When we make sense of a clinical situation we are noticing cues or changes in a patients condition. We take this information and interpret it to create a plausible story (or stories) and then we act — and the results of our actions serve as a test of the plausibility of the story. The better we are at sense-making the more subtle the cues and changes that we notice, the more plausible the stories that we create, the faster we act, and the more closely we monitor the results. The difference between the novice and expert sense-maker is perhaps exemplified best in anaesthestics, where experienced anaesthestists are quicker to detect changes in the patient’s physiological status, and quicker to act.
Noticing the cues is perhaps the most important step, and it is usually simply a matter of being surprised. This occurs when something unexpected happens. This implies that we had expectations of what was going to happen in the first place!
There are some powerful barriers that prevent us from noticing these cues.
We all share the universal human tendency to fall victim to confirmation bias, that is we tend to selectively remember and believe that which reinforces what we already believe to be true. Don’t believe me? Well, maybe you have succumbed to the blind-spot bias — the universal cognitive disposition of believing that you are less subject to cognitive biases than your fellow human beings! Another barrier is that we deal with conditions that constantly evolve. Premature closure, making a diagnosis that is not yet ripe to made, can shut down our monitoring system and lead to erroneous decision making. Finally, to create plausible stories for the complex undifferentiated patient requires intense mental effort, which is difficult to sustain amid the constant interruptions and time pressures of the emergency department.
So, how can we become better at sense-making?
Surely it is not just a matter of becoming old and wise. How can we become wise, but young?
Here are some strategies to help you make sense:
Deal with problems not diagnoses
Recognise that conditions constantly evolve in emergency situations and that we are prone to premature closure and confirmation bias. Diagnoses are always much easier in hindsight.
Learn to make explicit expectations so that violations are easier to spot.
Predict what should be found on examination and on investigations if the working diagnosis is correct, and force yourself to re-examine your interpretation if these findings are absent.
Develop the habit of stepping back to assess what is happening.
Periodically review cases and search for information that doesn’t fit.
Learn about situation awareness, how to become attuned to your environment and how to detect and correct errors.
Beware of ‘labels’
Labels are useful for interpreting cues but if too specific may lead to to entrapment bias. The importance of diagnosis is over-rated – undifferentiated RLQ pain is often a more useful label to work with than probable appendicitis or probable ovarian torsion. Keep labels broad, at least early in the diagnostic process.
Appoint a Devil’s Advocate
This is often the role of the attending/ ED consultant, but if you’re alone it will have to be you! The Devil’s Advocate should ask questions like: “What else could be going on? Why do you think that? Have you considered this? What if this happened?”
Seek a variety of interpretations
How does the physiotherapist, pharmacist, or nurse view what is happening? Different viewpoints give you more information to work with and help guard against confirmation bias.
Hopefully by becoming better sense-makers we can find that uneasy, but essential, balance between being able to commit to a decision and take action, yet still remaining open to change and avoiding entrapment.
- Christianson MK, Sutcliffe KM. Chapter 5. Sensemaking, High-reliability Organizing, and Resilience; in Croskerry P, Cosby KS, Schenkel SM, Wears RL Patient Safety in Emergency Medicine, Lippincott Wiliams & Wilkins, 2009.
(If you’re an emergency doctor you must read this book!)