In recent years we have witnessed a huge increase in the interest and activity around the areas of clinical decision making and cognitive aspects of our clinical practice. This is largely because of the herculean work and influences of emergency medicine heroes like Patrick Croskerry and Gloria Kuhn, constructing on the research and theories of authors like Daniel Kahneman and Steven Sloman.

We talk a lot about the nature of our decision making, the types of errors associated to it, if our naturalistic decision making follows a dual process theory vs. a continuum process theory, etc; but we bring very little attention to the object of the study: a decision.

What is a decision?;  above all is a cognitive process leading to a solution that implies a trade off.

This basic description highlights another aspect that is important; in an ideal world decision-making process considers all possible scenarios and solutions available to the problem, but in our real-life, decision-making is limited by information, time, skills and processing ability; this is what is called bounded rationality; being the corollary that strictly speaking our decisions are never rational.

The process behind the decision still not completely understood; but we now have a taxonomy of the components of a decision in how information and environmental aspects of the decision interact with the process itself.

Components of a decision:

• Alternatives or scenarios
• Consequences
• Preferences
• Action rules (playbook)

When facing a problem, you will probably generate a few cognitive solutions possibles for the problem; then you will assign expected consequences to every alternative and finally you will use a action rule based on unique preferences; quite commonly this preferences aim towards diminishing the potential lost vs. increasing a potential gain.

A functional definition of a decision is probably: a cognitive process based of units of information composed by alternatives, consequences, preferences and actions; leading to the solution of a problem and creating a trade-off between (risk/loss) and (gain/certainty).

Here two illustrations to understand the concept

How to choose ice cream flavor:

What to do with a patient with chest pain:

References

• Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009 Aug;84(8):1022-8.
• Sloman S. The empirical case for two systems of reasoning. Psychol Bull. 1996;119:3–22.
• March J.G. Primer on Decision Making: How decisions happen. p8-22. Free Press. 2009. Chapter 1: Limited rationality; p1-56.

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