What Do Physicians Believe About the Way Decisions Are Made? A Pilot Study on Metacognitive Knowledge in the Medical Context Research Reports What Do Physicians Believe About the Way Decisions Are Made? A Pilot Study on Metacognitive Knowledge in the Medical Context Paola Iannello*a, Valeria Peruccaa, Silvia Rivabc, Alessandro Antoniettia, Gabriella Pravettonibcd [a] Department of Psychology, Catholic University of the Sacred Heart, Milan, Italy. [b] Department of Health Sciences, University of Milan, Milan, Italy. [c] Interdisciplinary Centre for Research and Intervention on Decision (IRIDe Centre), Milan, Italy. [d] Institute of Oncology (IEO), Milan, Italy. Abstract Metacognition relative to medical decision making has been poorly investigated to date. However, beliefs about methods of decision making (metacognition) play a fundamental role in determining the efficiency of the decision itself. In the present study, we investigated a set of beliefs that physicians develop in relation to the modes of making decisions in a professional environment. The Solomon Questionnaire, designed to assess metacognitive knowledge about behaviors and mental processes involved in decision making, was administered to a sample of 18 emergency physicians, 18 surgeons, and 18 internists. Significant differences in metacognitive knowledge emerged among these three medical areas. Physicians’ self-reports about the decision process mirrored the peculiarities of the context in which they operate. Their metacognitive knowledge demonstrated a reflective attitude that is an effective tool during the decision making process. Keywords: medical decision making, metacognition, self-awareness, emergency care, surgery, internal medicine Europe's Journal of Psychology, 2015, Vol. 11(4), 691–706, doi:10.5964/ejop.v11i4.979 Received: 2015-03-30. Accepted: 2015-10-10. Published (VoR): 2015-11-27. Handling Editor: Rhian Worth, University of South Wales, Newport, United Kingdom *Corresponding author at: Department of Psychology, Catholic University of the Sacred Heart, largo Gemelli, 1, 20123 Milan, Italy. Phone: +39 0272342557. E-mail: paola.iannello@unicatt.it This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction In the field of the psychology of decision making, judgments and choices are usually investigated in laboratory situations, making it difficult to uncover the actual development of diagnostic processes in emergency departments (ERs). In real work situations, it is necessary to consider the inherent limitations of our cognitive structure, making it impossible to examine all aspects of the situation. We must also consider the environmental restrictions that arise from a context, which is itself problematic for analyzing the interactions of crucial and unavoidable variables that constantly confront the clinician. These factors include: 1) the risks which has to be taken and the associated uncertainty when these risks are not known (Kahneman, Slovic, & Tversky, 1982); 2) the need to update inform- ation on the basis of experience; 3) the simplification of thinking strategies (heuristics) to speed assessment (Marewski & Gigerenzer, 2012); 4) stress and lack of time, which trigger the paradox of avoiding decision making or of concentrating on a single source of information (Allnutt, 2002); 5) an excess of confidence in one’s abilities and the consequent exclusion of other unpredicted intervening factors (Croskerry, 2002); and 6) high emotional Europe's Journal of Psychology ejop.psychopen.eu | 1841-0413 http://creativecommons.org/licenses/by/3.0/ http://creativecommons.org/licenses/by/3.0 http://ejop.psychopen.eu/ http://ejop.psychopen.eu/ http://www.psychopen.eu/ impact, which can alter the calculation of probabilities and/or challenge rational selection processes (Hogarth, 1980). Metacognition constitutes a possible framework for considering this multiplicity of critical factors in a coordinated manner (Yzerbyt, Lories, & Dardenne, 1998). Metacognition primarily concerns the knowledge that everyone has about his/her own mental processes. This knowledge encompasses the thinking strategies used to deal with a cognitive task (solving a problem, remembering a notion, etc.), the emotional states that accompany them, the perception of effort made by the individual, and the obstacles encountered. Metacognition also includes beliefs in personal attributes, one’s cognitive abilities, task characteristics (level of complexity, etc.), the context in which one works (time constraints, etc.), and the demands and expectations that others develop about an individual’s actions. Metacognition can also be linked to the self-criticism that goes with professional competence, vigilance about one’s performance, availing oneself of advice, managing organizational conflicts, and recalling failures that are transformed into caveats for future behavior. Metacognition refers to the ability to control one’s mental processes and the behaviors derived from them, based on a person’s awareness of such behaviors and on the conviction that he/she develops regarding his/her optimal method of proceeding. In particular, metacognition related to decision-making processes – a little-studied aspect of clinical reasoning (Croskerry, 2000; Marcum, 2012; Pines, 2006) – refers to the level of knowledge an individual has regarding his/her method of making choices, the thinking strategies on which such choices are based, and the emotions experienced. Metacognition is the basis of the beliefs that individuals develop about the dynamics of the decision- making process, both with reference to their own personal characteristics (limits and strengths) and to the charac- teristics attributed to the ideal decision-maker. During the process of clinical decision making, metacognition seems to play a monitoring role, controlling or regulating the diagnostic/therapeutic decision (Marcum, 2012). Recent research suggests that metacognition could be successfully utilized to correct “imbalances” that arise due to biases in clinical reasoning (Lucchiari & Pravettoni, 2012). Additionally, metacognition allows the physician to evaluate the clinical decision-making process and to determine whether the process is worth applying to future decisions (Marcum, 2012). A recent study suggests that individual differences in metacognitive competence may effectively predict the outcomes of clinical decision-making processes (Jackson & Kleitman, 2014). If the physician is fully aware of his/her method of decision making and reports adequate convictions about how decisions should be made, he/she should be able to exercise control over the decision-making process, plan it in a satisfactory manner, and change it when required. Aims The objectives of this study were: 1) to explore the metacognitive knowledge that physicians possess about the way they make their decisions in the workplace; 2) to detect differences, if any, in metacognitive knowledge among various medical professions; and 3) to determine whether metacognitive knowledge differs according to the physician’s level of expertise. Methods Ethics Statements Participants in the experiments described here were treated according to the ethical standards of the American Psychological Association. Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 692 http://www.psychopen.eu/ In accordance with the procedure adopted in the investigators’ department, which seeks to avoid submitting projects to the Ethics Committee that cannot be problematic from the ethical point of view, this project was submitted to the Head of the Department to assess the need for submission to the Ethics Committee. Consultation with the Chairman of the Ethics Committee determined that the research did not require submission to the Ethics Committee. The first page of the Solomon Questionnaire explicitly stated that participants would remain anonymous. Research- ers had no way to identify the physicians, which would have been possible if written consent was obtained from participants. After explaining the purpose of the study, potential participants were asked whether everything was clear and whether they consented to participate. Participants The questionnaire was administered to 54 physicians: 18 ER physicians, 18 general surgeons, and 18 internists. Physicians were located at four hospitals in Northern Italy: Ospedale di Borgosesia (Vercelli), Ospedale di Busto Arsizio (Varese), Ospedale San Carlo (Milano), and Ospedale Valduce (Como). The sample consisted of 36 men and 18 women, with more male surgeons and internists (83% men in surgery, 66% in internal medicine, and 50% in the ER). Participant age ranged between 26 and 60 years (mean (M) = 44.92 years; standard deviation (SD) = 9.21 years). The mean ages of the three groups of specialists did not significantly differ (ER: M = 39.06 years, SD = 8.87 years; surgery: M = 46.51 years, SD = 9.65 years; internal medicine: M = 49.14 years, SD = 9.01 years; F(2, 53) = 1.67, p = .17, η2 = .02). Additionally, differences in age among the four hospitals were not significant (Borgosesia: M = 45.05 years, SD = 10.00 years; Busto Arsizio: M = 41.96 years, SD = 9.81 years; Milano: M = 46.62 years, SD = 9.81 years; Como: M = 43.32 years, SD = 9.63 years; F(3, 53) = 1.91, p = .20, η2 = .04). The experience of the physicians within each specialty varied between 1 and 34 years and was significantly cor- related with age (r = .91). Consequently, only data about experience were analyzed. Seniority was considered to reflect the level of expertise of the responders and was divided into three categories: low (< 9 years; N = 22), medium (9-23 years; N = 14), and high (> 23 years; N = 18). The three levels of expertise did not significantly differ among the four hospitals, χ2(6, N = 54) = 21.24. Once we verified the homogeneity of the four subsamples in terms of physician age and level of expertise, the subsamples were pooled. Note that all four hospitals are situated within a 100-km radius, in an area with similar geographic and demographic features. The socioeconomic and educational levels of the patients in these hospitals are the same. All hospitals belong to the national health care system (none of them are private), and therefore they use the same rules and protocols. Materials The Solomon Questionnaire (Colombo, Iannello, & Antonietti, 2010) was used to investigate metacognition in decision making. A version of the original questionnaire was adapted to the specific medical contexts of the present study. The questionnaire (Appendix) consisted of two parts. In the first part, metacognitive knowledge about the personal strategy for making decisions was investigated on two levels. The descriptive-behavioral level (Items 1-6) defines the approach to decisions that the respondent generally applies during his/her working activity. The procedural- emotional level (Items 7-8) concerns the processes involved in decision making and the cognitive strategies and Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 693 http://www.psychopen.eu/ emotional reactions that are triggered during decision making. The second part of the questionnaire addressed the respondent’s metacognitive knowledge about the decision process in general, as well as the individual char- acteristics that, according to one’s own ideas, identify a “good decision-maker” (Items 9-15). Categorization of Responses to Open Questions In order to analyze the responses to the open questions in the Solomon Questionnaire, responses were grouped into semantic categories (Table 1). Table 1 Semantic Category System for Coding Questionnaire Responses CategoryCorresponding questionFocus of the questionItems 2. Describe briefly three typical decisions of your working day “Typical” decisionItem 2 • admittance/discharge • therapy (prescribe or change) • surgery or invasive tests • diagnosis 8a. Describe the general situation, i.e. the context in which you are required to make a decision Decision contextItem 8a • urgency • routine • management and organizational problems • confusion (many patients at the same time, difficulty perceived) 8b. Which is your first thought?First thoughtItem 8b • not to cause harm • focus on the patient (putting oneself in his/her shoes, concentrating attention on him/her) • asking oneself questions/reflection 8c. How do you feel when you make this decision?Personal feelingItem 8c • calm/peaceful • stressed/inadequate • concentrated/absorbed • other (rage/excitement/fear/powerless) 8d. What do you do to make this decision?Which actions?Item 8d • alternative investigation/consultation with others • strategy (assessment of costs/benefits, preparation of an action plan) • accumulated knowhow • instinct 8e. Do you face the situation by yourself or do you ask others for help/advice? Confronting the problem with others?Item 8e • alone • others • it depends/if I do not have other means 8f. Do you basically employ solutions that turned out to be effective in the past or do you tend to try out new solutions? Learning from the past?Item 8f • effective in the past • I experiment • it depends • both 8g. Once you have made the decision, do you follow it or do you modify it (entirely or in part)? On the basis of Adhering to the first plan?Item 8g • I adhere to the decision • I change the decision during the process (due to new available data, changes in the condition of the patient) which thoughts/reflections do you modify/don't modify your decision? 9. Which peculiarities characterize those people who are effective in taking their decisions? Characteristics of the “good decision-maker” Item 9 • experience/competence • intuition/strength of character • intelligence/metacognitive skills (equilibrium, reflection, self-awareness) 10. A good decision maker is someone who never regrets his/her decision? Why? Regret and the “good decision-maker” Item 10 • it is possible to make mistakes • it is possible to learn from one’s mistakes • self-criticism (necessary) 13. How do you think a person can become a good “decision-maker”? How to become a “good decision-maker” Item 13 • experience • training/teachers • increasing one’s own metacognitive awareness (understand how one makes decisions, awareness of one’s limits) Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 694 http://www.psychopen.eu/ CategoryCorresponding questionFocus of the questionItems 14. How can you help someone to make good decisions? The way to support “good decision making” Item 14 • give advice • develop self-esteem/metacognition • act as an example 15. Which could be a proper example of a “good decision-maker”? (you can mention historical or Examples of a “good decision-maker”Item 15 • colleagues/superiors • family members/friends • current politicians mythological characters, well-known people, but also colleagues, relatives or friends) • historical figures • fantasy/mythological figures Results Part 1 of the Questionnaire: Metacognitive Knowledge About the Personal Way of Making Decisions Self-reported data from the overall sample (Table 2) indicate that a hospital physician makes an average of 31.5 decisions (range = 3-100 decisions) during a typical working day. A 6-h working day would yield ~5 decisions/hour. Typical decisions mainly concern diagnosis (37%) and therapy (28%). Of these decisions, 69.2% indicated that they involve direct physician responsibility, 56.3% are reversible, 38.9% said that they are mainly related to the physicians themselves, 23.4% require a lot of time to be reached, and 13% are accompanied by a feeling of regret – because the decision-maker believes, in retrospect, that a different choice would have been preferable. The context in which decisions was reported to be routine (37%) and urgent (31.5%). Above all, decisions seemed to be accompanied by an attempt to not cause harm and to avoid aggravating the patient's clinical situation. Feelings of stress and inadequacy or of peace and calm appeared to arise during the decision-making process. Of the re- sponding physicians, 37% declared that they rely on their strategic skills, whereas 22.2% reported that they base their decision on their knowhow. The majority of interviewed physicians said that they ask others for help when possible and use strategies that were effective in the past. Finally, half of the sample reported that they change their initial decision when new elements emerge. One-way analysis of variance (ANOVA) with medical specialty as an independent variable was carried out using the closed questions in the first part of the questionnaire (Table 2, Items 1 and 3-7). We detected significant dif- ferences among the categories of physicians for Item 5 (F(2.53) = 3.79, p < .05, η2 = .18). Bonferroni’s post-hoc test (p < .05) showed that decisions related to oneself were more relevant to ER physicians than to surgeons. Although the differences among specialty groups did not reach statistical significance, it is worth noting that ac- cording to these self-reported data, the greatest number of decisions are made in ERs, especially compared to the average number of decisions reported by internists. Direct responsibility for decisions did not differ among the three specialist groups. The data indicated the same trend for ER physicians and internists, who reported a greater number of decisions with direct responsibility than surgeons. Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 695 http://www.psychopen.eu/ Table 2 Responses to Questions in the First Part of the Questionnaire According to Specialty pTotal sample Specialty CategoryItem – Focus of the question Internal MedicineSurgeryEmergency 31.5 (28.5)23 (4.4)40.4 (7.3)Item 1 - Average number of decisions [M (SD)] .147.0% (7.6)31 Item 3 - Decisions with direct responsibility .289.2%69.0%75.4%59.2%73 Item 4 - Reversible decisions .628.3%56.5%58.4%56.1%54 Item 5 - Decisions related to oneself .041.9%38.1%41.2%24.4%51 Item 6 - Decisions that require a lot of time .594.4%23.0%25.1%21.9%23 Item 7 - Decisions followed by regret .193.0%13.3%11.8%15.8%11 Item 2 - Typical decision (frequency) .003 11128admittance/ discharge 151050Therapy 8143surgery or invasive tests 20677Diagnosis Item 8a - Context (frequency) .102 17485Urgency 201064Routine 9333management and organizational problems 8116Confusion Item 8b - First thought (frequency) .980 21777not to cause harm 11434focus on patient 21786ask oneself questions/ reflect Item 8c - Feelings (frequency) .411 11632Calm 20677Stressed 15564concentrated/ totally absorbed 8125other Item 8d - What one does to reach a decision (frequency) .388 17647investigate alternatives/ consultation 20857Strategy 12462accumulated knowhow 5032Instinct Item 8e - Decide alone/ with help (frequency) .218 16736Alone 16286with others 22976It depends/if I can Item 8f - Experiment with solutions (frequency) .366 319139effective in the past 4202I experiment 7421it depends 12336Both Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 696 http://www.psychopen.eu/ pTotal sample Specialty CategoryItem – Focus of the question Internal MedicineSurgeryEmergency Item 8g - Adhere to decisions made (frequency) .046 16277I adhere to my decisions 271467I change decisions in progress 4013I change after reflection 7241it depends The distributions of the categorized responses to the open questions were analyzed with contingency tables and the relative χ2 test (Table 2, Items 2 and 8a-g). There were significant differences in the types of decisions made by the specialists (χ2(6; N = 54) = 19.66, p < .005) based on the item “Describe three typical decisions of your working day.” More specifically, ER physicians reported that they more frequently had to make decisions about patient admission or discharge, whereas internists stated that they made more decisions about therapy. Responses to item 8g (“Once you have made a decision, do you adhere to that decision or do you change it? On what basis of thought process/observations do you change or not change your decision?”) were differently distributed among the specialty groups (χ2(6, N = 54) = 12.81; p < .05); internists reported that they changed decisions more frequently than did the other two specialty groups. One-way ANOVA including the level of expertise as an independent variable was carried out using the closed questions in the first part of the questionnaire (Table 3, Items 1 and 3-7). Results suggested that younger physicians make a greater number of decisions than older practitioners (F(2.53) = 2.98, p < .05, η2 = .17). Although the dif- ferences among expertise groups did not reach statistical significance, younger physicians tended to make fewer decisions with direct responsibility than members of the other two groups. Table 3 Responses to Questions in the First Part of the Questionnaire, According to Level of Expertise p Level of Expertise CategoryItem – Focus of the Question HighMediumLow 23.7 (6.1)30.3 (6.4)38.5 (6.8)Item 1 - Average number of decisions [M (SD)] .049 Item 3 - Decisions with direct responsibility .190.9%73.9%73.4%62 57.0%Item 4 - Reversible decisions .546.9%53.6%58 42.0%Item 5 - Decisions related to oneself .245.5%35.3%38 Item 6 - Decisions that require a lot of time .764.9%23.2%22.7%23 Item 7 - Decisions followed by regret .354.4%15.1%11.3%12 Item 2 - Typical decision (frequency) .211 146admittance/ discharge 843therapy 413surgery or invasive tests 5510diagnosis Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 697 http://www.psychopen.eu/ p Level of Expertise CategoryItem – Focus of the Question HighMediumLow Item 8a - Context (frequency) .097 548urgency 1154routine 234management and organizational problems 026confusion Item 8b - First thought (frequency) .982 759not to cause harm 335focus on patient 858ask oneself questions/ reflect Item 8c - Feelings (frequency) .306 722Calm 668stressed 447concentrated/ totally absorbed 125Other Item 8d - What one does to reach a decision (frequency) .278 386investigate alternatives/ consultation 938strategy 525accumulated knowhow 113instinct Item 8e - Decide alone/ with help (frequency) .865 637Alone 457with others 868it depends/if I can Item 8f - Experiment with solutions (frequency) .848 10912effective in the past 202I experiment 313it depends 345Both Item 8g - Adhere to decisions made (frequency) .150 439I adhere to my decisions 12510I change my decision in progress 022I change after reflection 241it depends The distributions of the categorized responses to the open questions were analyzed with contingency tables and the relative χ2 test (Table 3, Items 2 and 8a-g). No significant differences were detected. Part 2 of the Questionnaire: Metacognitive Knowledge About the Characteristics of the “Good Decision-Maker” Data from the entire sample (Table 4) highlighted the image of the “good decision-maker” as a person with exper- ience and competence (57%). Respondents also thought that a good decision-maker was a person who may feel regret (94.5%); self-criticism was considered an important quality that stimulates metacognition and aids learning (43%). In 90.7% of responses, being a good decision-maker was considered to arise from interactions between innate and learned skills. Respondents reported that physicians can become good decision-makers through ex- perience (47%) and consultation with others (30%) and can help others to be good decision-makers by setting a Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 698 http://www.psychopen.eu/ good example (52%) and promoting metacognition and self-esteem (34%). Decisions made after careful thought were considered to be of higher quality (74%), and political figures and people from the past were given as examples of good decision-makers (35%). Table 4 Responses to Questions in the Second Part of the Questionnaire, According to Specialty. pTotal Sample Specialty CategoryItem – Focus of the question Internal MedicineSurgeryEmergency Item 9 - Traits of a good decision-maker (frequency) .201 3191111experience/competence 11254intuition/strength of character 11722intelligence/ metacognitive skills Item 10 - A good decision-maker feels regret .250.5%94.5%94.0%100.9%88 Item 10bis - Feels regret because (frequency) .856 12534one can make mistakes 13454one can learn from one’s mistakes 19847self-criticism Item 11 - The best decisions require careful thought .160.0%74.9%88.6%66.6%66 Item 12 - The ability of being a good decision-maker is (frequency) .551 3021Innate 2101Learned 49171616Both Item 13 - How one can become a good decision-maker (frequency) .484 236107Experience 15735training/teachers 11335increasing one’s metacognitive awareness Item 14 - How one can help others become good decision-makers (frequency) .790 11425giving advice 17575developing self-esteem/ metacognition 21777setting an example Item 15 - Examples of a good decision-maker (frequency) .768 9333colleagues/superiors 9243family members/friends 6222current politicians 15276historical figures 3201fantasy/mythological figures One-way ANOVA was conducted for closed questions (Table 4, Items 9 and 10bis), and the distributions of cat- egorized responses to the open questions were analyzed with contingency tables and the relative χ2 test (Table 4, Items 9, 10bis, and 12-15). These analyses uncovered no significance differences. However, ER physicians and surgeons tended to value experience as the major characteristic of a good decision-maker, whereas internists placed greater importance on intelligence and metacognitive skills. Additionally, the entire group of surgeons (100%) considered regret to be a fundamental characteristic of a good decision-maker; fewer ER physicians (88.9%) expressed this opinion. Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 699 http://www.psychopen.eu/ One-way ANOVA was conducted for closed questions (Table 5, Items 9 and 10bis) to explore the perceived effect of expertise on decision making. The differences among expertise groups were not significant for either item. Our data indicated that all physicians with the highest level of expertise considered the ability to feel regret as funda- mental for being a good decision-maker, whereas 90.0% of physicians with low and medium levels of expertise valued regret as a feature of the good decision-maker. Fewer respondents with a medium level of expertise believed that the best decisions require careful thought (64.3%) versus physicians with a high level of expertise (83.3%). Table 5 Responses to Questions in the Second Part of the Questionnaire, Grouped by Level of Expertise. p Level of Expertise CategoryItem – Focus of the question HighMediumLow Item 9 - Traits of a good decision-maker (frequency) .090 11713experience/competence 236intuition/strength of character 533intelligence/ metacognitive skills Item 10 - A good decision-maker feels regret .379.0%100.8%92.9%90 Item 10bis - Feels regret because (frequency) .570 534one can make mistakes 418one can learn from one’s mistakes 658self-criticism Item 11 - The best decisions require careful thought .150.3%83.3%64.6%72 Item 12 - The ability of being a good decision-maker is (frequency) .702 102Innate 101Learned 161419Both Item 13 - How one can become a good decision-maker (frequency) .554 779Experience 339training/teachers 443increasing one’s metacognitive awareness Item 14 - How one can help others become good decision-makers (frequency) .080 317giving advice 359developing self-esteem/ metacognition 1056being of example Item 15 - Examples of a good decision-maker (frequency) .908 324colleagues/superiors 414family members/friends 222current politicians 555historical figures 201fantasy/mythological figures χ2 values were calculated for the distributions of the categorized responses for each open question in terms of expertise (Table 5, Items 9, 10bis, and 12-15). Two non-significant trends emerged. Regarding the ways in which one can help a person become a good decision-maker, physicians with higher levels of expertise mainly opted for “setting an example,” whereas physicians with low levels of expertise preferred reflection and support over Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 700 http://www.psychopen.eu/ self-esteem (p = .08). Last, physicians with high and low levels of expertise more often attributed experience and competence to being a good decision-maker as compared to physicians with medium level of expertise (p = .09). Discussion and Conclusions The results of the current study highlight several interesting aspects of the metacognition of decision making by physicians. For example, the types of decisions made in the various medical departments were different. Whereas ER physicians reported that they more often make decisions about patient discharge and admission, internists reported that they are more involved with decisions related to therapy. This result is plausible because ER physicians must deal with a large number of acute patients, whereas internists are required to identify a therapy after diagnosis. The present study underscores that physicians in the ER generally make decisions about themselves more often than internists and surgeons do. This result may be better understood in light of the peculiar characteristics of ERs, where physicians are more often called upon to reflect on and continuously review their conduct (Antonietti, Andolfi, & Colombo, 2014). A further difference between the ER and internal medicine lies in the number of decisions that are changed over time. The predominance of strategic changes following the availability of new data in internal medicine appears understandable due to the more routine structure in which internists operate, which consequently gives them more time to review their position. Participants reported that most decisions are generally made quickly; few are followed by regret. In all specialties, nearly half of respondents in the present investigation said that the possibility of feeling regret is a significant characteristic of a good decision-maker, likely motivated by the conviction that a careful critical analysis of the decision can lead to an improvement of one’s metacognition skills and therefore in the quality of one’s decisions (Riva, Monti, Iannello, & Antonietti, 2012). The impossibility of concealing surgical errors and the practitioners’ years of experience may explain why the entire sample of physicians with high levels of expertise deemed funda- mental the ability to feel regret (Murphy, Stee, & McEvoy, 2007). In line with the literature on anticipated regret (Zeelenberg, 1999), our respondents indicated that the more difficult a decision (in medical decision making, this difficulty could be due to uncertainty about the risks and outcomes of each option), the more likely it is that indi- viduals consider regret to be an integral part of the decision making process. Results from the present study suggest that physicians not only take regret into account when deciding, but consider the emotional experience of regret as a fundamental feature of a good decision-maker. It is likely that both the anticipation and the post- decisional experience of regret may induce decision-makers to make better choices; regret causes them to think and reflect accurately during each step of the decision making process. As a form of reflection and a balance of costs/benefits, metacognition seems to be an appropriate approach modality to decision making by physicians. The importance of metacognition is confirmed by our observation that younger physicians in particular consider it fundamental to stimulate self-esteem and professional skills in order to become good decision-makers. In contrast to the assumptions of normative decision making models in which the decision-maker should rationally analyze all pieces of information available at that moment, this study showed that decisions are often based on acquired knowledge and on strategies that were effective in the past, irrespective of possible mismatches between the current situation and previous ones (Riva, Monti, & Antonietti, 2011). Here, experience accumulated over time Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 701 http://www.psychopen.eu/ seems to play a central role in the decision making process; it was highlighted as one of the most important characteristics that a good decision-maker should have (Riva et al., 2014). The present work is a pilot study, and our findings require further investigation. The major limitation of this study is the sample size, which is relatively small to support broad generalizations. However, we hope that the present research will contribute to an interesting topic that is not yet well described in the literature. We anticipate that these data will be useful for establishing a tentative instrument for physicians to increase their metacognitive awareness in decision making. In conclusion, based on these self-reported data, we conclude that physicians are aware that they are acting and operating within a context of uncertainty, with a high risk of error. Overall, the current results indicate a certain sensitivity to the attitude of reflection, which respondents deemed useful and effective for providing support to physicians during the decision making process. Funding The authors have no funding to report. Competing Interests The authors have declared that no competing interests exist. Acknowledgments The authors have no support to report. References Allnutt, M. F. (2002). Human factors in accidents. 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Descriptive-behavioral section 1. How many decisions connected with your occupation do you make during a day on average? ……… 2. Describe briefly three typical decisions you make in your working day: I: …………………………………………………. II: …………………………………………………. III: …………………………………………………. 3. Think about the decisions you make at work in a day: - decisions are you the only and direct person responsible for: how many? .....% - decisions you share with others the responsibility and the consequences of: how many? .....% Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 703 http://dx.doi.org/10.1111%2Fj.1365-2753.2011.01771.x http://dx.doi.org/10.1111%2Fj.1365-2753.2012.01900.x http://dx.doi.org/10.1378%2Fchest.06-2420 http://dx.doi.org/10.1197%2Fj.aem.2005.07.028 http://dx.doi.org/10.2147%2FAMEP.S13004 http://dx.doi.org/10.1371%2Fjournal.pone.0048297 http://dx.doi.org/10.1371%2Fjournal.pone.0090941 http://dx.doi.org/10.4135%2F9781446279212 http://dx.doi.org/10.1002%2F%28SICI%291099-0771%28199906%2912%3A2%3C93%3A%3AAID-BDM311%3E3.0.CO%3B2-S http://www.psychopen.eu/ 4. Some decisions could be defined as “reversible” since, once you become aware of their ineffectiveness and inappropriateness, you can modify them, partly or entirely; on the contrary, as for other decisions, which can be defined as “irreversible”, once you take them, you can not change them. Think about the decisions you make at work during a day: - how many of them are reversible? .....% - how many of them are irreversible? .....% 5. Think about the decisions you make at work: - how many of them concern exclusively or mainly yourself? ....% - how many of them concern also other people? ....% 6. Thinking about the time you spend in making decisions at work: - how many of them take a lot of time to be made? ....% - how many of them are made quickly and immediately? ....% a2. Procedural-emotional section 7. Thinking about the decisions you make during your working day: - how many times do you regret your decisions? ....% - how many times don’t you regret your decisions? ....% 8. Keep on thinking about your working day. Identify a typical situation, or at least a situation that you often experience, in which making a decision is really demanding and difficult. 8a. Describe the general situation, that is, the context in which you are requested to make this specific decision ……………………………………………………… 8b. Which is your first thought? ……………………………………………………… 8c. How do you feel when you make this kind of decision? ……………………………………………………… 8d. What do you do to make this decision? ……………………………………………………… 8e. Do you face the situation by yourself or do you ask others for help/advice? ……………………………………………………… 8f. Do you basically employ solutions that turned out to be effective in the past, or do you tend to try out new solutions? ……………………………………………………… 8g. Once you have made the decision, do you follow it, or do you modify it (entirely or partly)? On the basis of which thoughts/reflections do you modify /don’t modify your decision? ……………………………………………………… Part b: “The good decision-maker in general” 9. In your opinion, which peculiarities characterize those people who are effective in taking their decisions? …………………………………………………………………… Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 704 http://www.psychopen.eu/ 10. A good decision maker is someone who never regret his/her decision? _ Yes _ No Why ………………………………………………………………………………………………………… 11. Best decisions are: _ intuitive _ analytical 12. According to your opinion, the competence of being “a good decision maker” is: _ innate _ learned _ partly innate, partly learned 13. If you believe that the competence of making good decisions can be learned or improved, how do you think a person can become a good decision maker? ……………………………………………………… 14. How can you help someone to make good decisions? ……………………………………………………… 15. Which could be a proper example of a “good decision maker”? (you can mention historical or mythological characters, well-known people, but also colleagues, relatives or friends) ……………………………………………………… About the Authors Paola Iannello, PhD, is researcher in cognitive psychology and member of the research unit on “Decision-making processes in emergency medicine” at the Catholic University of the Sacred Heart. Her research interests mainly concern medical and economic decision making and, specifically, how individual differences in personality affect decision-making processes. Valeria Perucca, an anthropologist and a clinical psychologist: she is cooperating with the Catholic University of the Sacred Heart in a research project on Decisional Process in Health and with the Academy of Emergency Medicine and Care on the Doctors’ and Patients’ Medical and Anthropological Aspects. Alessandro Antonietti is full professor of cognitive psychology at the Catholic University of the Sacred Heart in Milan, Italy. He is the director of the Research Center for Vocational Psychology and Career Guidance and of the Learning and Educational Psychology Service. His interests concern learning, reasoning, decision making and creativity. Silvia Riva is a post-doc researcher at the University of Milan. She studies the cognitive mechanisms underlying judgments and decisions and how they are influenced by the characteristics of the environment and the skills of the decision maker. Her research is mainly focus on medical decision making Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 Iannello, Perucca, Riva et al. 705 http://www.psychopen.eu/ Gabriella Pravettoni is Full Professor of Psychology of Decision Making – DIPO (Department of Oncology and Hemato – Oncology), University of Milan, Director of the Applied Research Division for Cognitive and Psychological Science at IEO – Milan, Coordinator of Doctorate Folsatec (Foundations of the life sciences and their ethical consequences) – at SEMM (European School of Molecular Medicine), Milan. PsychOpen is a publishing service by Leibniz Institute for Psychology Information (ZPID), Trier, Germany. www.zpid.de/en Europe's Journal of Psychology 2015, Vol. 11(4), 691–706 doi:10.5964/ejop.v11i4.979 A Pilot Study on Metacognitive Knowledge in the Medical Context 706 http://www.psychopen.eu/ http://www.zpid.de/en A Pilot Study on Metacognitive Knowledge in the Medical Context Introduction Aims Methods Ethics Statements Participants Materials Categorization of Responses to Open Questions Results Part 1 of the Questionnaire: Metacognitive Knowledge About the Personal Way of Making Decisions Part 2 of the Questionnaire: Metacognitive Knowledge About the Characteristics of the “Good Decision-Maker” Discussion and Conclusions (Additional Information) Funding Competing Interests Acknowledgments References Appendix: Solomon Questionnaire Part a: “You as a decision-maker” Part b: “The good decision-maker in general” About the Authors