REACT
The problem of communicating and working with risk and uncertainty is a serious one for many fields, none more so than medicine. This project was motivated by the need to provide support for clinicians and patients involved in complex medical planning tasks.Software exists for supporting clinical decision making, but generally only for a single, isolated decision - for example, what drug to prescribe, or whether to refer a patient to a specialist. Similarly theoretical and experimental work in cognitive psychology has largely concentrated on single decisions rather than the wider set of cognitive processes which are involved in framing decision-making as a part of planning and plan execution. Most decisions, however, are made in the context of plans of action, where they may interact or conflict with other planned actions or anticipated events. For example, the planning of medical interventions over a patient's lifetime is a complex proposition with many sources of information, interactions and dependencies between interventions.
For example, consider the case of a woman diagnosed as carrying a mutation to the gene BRCA1 which predisposes to breast cancer. Such a woman may have a lifetime risk of developing breast cancer approaching 80%. Following identification of the genetic factor, the woman will typically be seen by a genetic counsellor who explains what the impact of this will be, and what options are available for mitigating the risk. A number of options are available, including treatment with drugs, screening to detect tumours early in development, and surgery to remove the ovaries or breasts.
There is no "correct" plan of action in this situation, the care plan arrived at by the counsellor and patient will reflect the individual needs and plans of the patient. For example, she may be planning to have children, and will need to avoid ovarian surgery and certain drugs. She may plan to have ovarian surgery in a few years time but to wait until much later in her life, when breast cancer risk is higher, before considering breast surgery. Each decision involved in forming the plan is influenced by previous decisions, and can influence later decisions.
The principal objectives for this project were 1) to develop a theoretical understanding of the cognitive processes involved in planning, and to link this to practical support techniques that could be provided by a computer system; 2) to design and develop computer software that could be used clinically, and finally 3) to use the software and psychological experimentation to empirically validate the theoretical position. These objectives have been achieved.
A theoretical view of judgement, decision making and planning was developed which encompasses the full set of processes surrounding these abilities, including the assessment of decision options, the bringing to bear of diverse bodies of knowledge in decision making, and the ability to reason and communicate about the decision making process. Work was carried out to establish relationships between this theoretical framework and existing psychological, neuropsychological and artificial intelligence (AI) theory.
The theoretical approach was then related to practical means by which decision support software could assist the cognitive processes of planning, through consideration of the cognitive loads involved in the various processes of plan manipulation. Experimental work established that the most significant of these cognitive loads did indeed play a part in the difficulty of planning and could be mitigated by appropriately designed computer feedback.
A computer application was designed, called REACT (Risk, Events, Actions and their Consequences over Time), to provide support to people involved in planning tasks in complex, uncertain domains such as medicine. The software provides an interactive planning chart on which a plan may be drawn and modified, and it provides immediate feedback, while the plan is being changed, of the consequences of any changes and any important information the user should be aware of. REACT can be applied in any situation where plans must be made in the context of a great deal of complex and potentially conflicting information, but we have applied it to medical care planning for the purposes of this project. The REACT software can be used to support an expert planner, or to support joint planning between an expert and a novice. This is the situation for example in the type of medical planning task discussed above, where a clinician and a patient jointly work on a care plan.
An evaluation study was carried out using actors to play patients in a simulated clinical situation like the one discussed. Clinicians used the REACT software to jointly work on a care plan with the simulated patients. The results were highly encouraging, with seven of the eight participating clinicians very positive about using the software clinically, and all feeling the software to be worthwhile.
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