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A special issue of the Human Factors and Ergonomics Society (HFES)’s Journal of Cognitive Engineering and Decision Making explores the competing perspectives on evidence-based medicine, best practices, and the quality movement in healthcare. The issue looks into the appeal of Evidence-Based Medicine (EBM) and how some fear that clinicians may be nudged to follow simple decision rules rather than actively solve problems and apply their clinical judgment. Thought leaders in EBM and Naturalistic Decision Making (NDM) discuss the challenges of implementing EBM, the promise, and potential unintended negative consequences.
Journal editors Laura Militello and Michael Weiner explain that the intent of this special issue is to, “stimulate further discussion, increase collaboration across disciplines, and spur innovation in supporting clinical decision making for both clinicians and patients.”
The special issue opens with an article written by Paul Falzer of the VA Connecticut Healthcare System. In his article, “Naturalistic Decision Making and the Practice of Healthcare,” Falzer makes the case that a better understanding of how clinicians make decisions in the dynamic clinical setting amidst interruptions, distractions, and uncertainty can help designers and policymakers avoid reducing complex medical situations to simple algorithms. Falzer provides historical background for the “best practices regimen” and an in-depth discussion of decision making in this context.
The issue also contains commentary on Falzer’s article from multidisciplinary experts, revealing that that the understanding of the term “evidence-based medicine” varies within different communities. R. Bryan Haynes counters Falzer’s opinion suggesting that, “…the target is painted on the wrong back. EBM doesn’t typically use the term best practices and, from the beginning, has seen the clinical application of evidence from research as requiring the clinician’s experience, expertise, and judgment; the patients’ individual circumstances; and the patients’ preferences and rights…”
Some, such as Robert Hamm and Zsolt Nagykaldi, support and build upon Falzer’s case for the value of NDM in improving applications of EBM: “We encourage these [human factors, cognitive engineering, and NDM] researchers to partner with primary care practitioners and researchers to find ways to improve procedures for delivering the best care to patients, for supporting patients in attaining their health goals, and for restoring physician “joy in practice.”
Other experts included question whether there is any evidence indicating that NDM would contribute. Matlock and Glasgow caution, “… one might interpret the author’s argument to suggest that NDM improves quality by continuing to support proficient experts to ignore patient preferences and drive up health care costs – an argument that is not only not helpful, but potentially harmful.”