Embodied Clinical Decision-Making in Osteopathic Manipulative Medicine Published in The AAO Journal • Vol. 25, No. 2 • September http://digital.turn-page.com/i/576658-september-2015/12 2015 Citation Esteves JE (2015). Embodied clinical decision making in osteopathic manipulative medicine. American Academy of Osteopathy Journal 25 (2), 13-6. 1 Embodied Clinical Decision-Making in Osteopathic Manipulative Medicine Jorge E. Esteves, PhD, MA, BSc (Ost), DO (United Kingdom) From the British School of Osteopathy in London. Jorge E. Esteves, PhD, MA, BSc (Ost), DO (United Kingdom), has practiced osteopathy in England since 1993. He is currently the head of research at the British School of Osteopathy in London. Apart from his academic work at the British School of Osteopathy, Dr Esteves is also an osteopathy subject reviewer for the United Kingdom’s Quality Assurance Agency for Higher Education and a nonexecutive council member of the United Kingdom’s General Osteopathic Council. Previously, Dr Esteves was instrumental in developing and implementing the osteopathic pre-registration education at Oxford Brookes University in Oxford, England. Dr Esteves completed his PhD at Oxford Brookes University in 2011, where his research focused on examining diagnostic palpation in osteopathy and developing neurocognitive models of expertise. Dr Esteves is interested in investigating how expert osteopaths process and bind together diagnostic data across senses. In particular, he is interested in examining the way in which diagnostic data conveyed by different senses converge in the brain to form a perception of soft tissue dysfunction. Financial disclosure: none reported Correspondence address: Jorge E. Esteves, PhD, MA, BSc, (Ost), DO (United Kingdom), British School of Osteopathy 275 Borough High St London SE1 1JE United Kingdom +44 (0)20 7089 5310 j.esteves@bso.ac.uk Submitted for publication May 20, 2015; final revision received September 14, 2015; manuscript accepted September 18, 2015. Introduction According to authors in the field, osteopathic manipulative medicine (OMM) is practiced according to an articulated and unique philosophy that distinguishes it from other healthcare professions.1 Osteopathic clinicians seek to understand the causes of impaired health, with the aim of providing individually tailored care. Within this practice paradigm, it is claimed that the diagnosis of somatic dysfunction is central to clinical decisionmaking because somatic dysfunction normally indicates impaired or otherwise altered function of the body framework.1 In contrast, I would argue that the decision-making processes and thinking dispositions of clinicians in the field of OMM are likely to be universal and, therefore, similar to those used in other medical domains and in everyday life. Although osteopathic models of diagnosis and care imply an element of causality and systematic analytical reasoning, the reality is that our decision-making is largely dominated by intuition. In fact, we make thousands of decisions daily without realizing we make them. We spend approximately 95% of our time in the “intuitive” mode.2 Intimately associated with intuition is the diagnosis of somatic dysfunction. Clinicians diagnose somatic dysfunction based on information obtained during subjective and objective examinations of their patients. This information is largely gathered through the clinicians’ senses, ie, through the visual, haptic (tactile and proprioceptive), auditory, vestibular, and interoceptive systems. Consequently, the diagnosis is heavily 2 influenced by perceived patterns of tissue dysfunction, which engages clinicians’ intuition rather than their analytical skills. In certain situations, we can comfortably trust our intuition (eg, left-sided arm and chest pain indicates myocardial infarction). However, there are instances in which it would be inappropriate to use anything other than analytical reasoning.3 When the “wrong” decision-making system is used or when judgments are made without sound evaluation, systematic errors known as cognitive and affective biases are likely to occur.4 These are likely to be highly prevalent in a profession underpinned by a distinctive philosophy of clinical practice that relies heavily on diagnostic palpation. Clinical decision-making, the thinking and reasoning process that informs and underpins autonomous clinical practice, involves the interrogation and application of declarative knowledge, procedural knowledge, reflection, and evaluation.5 Considering the current literature on embodied cognition, I would argue that clinical decisionmaking in OMM is not limited to cognitive processing but rather that it is an embodied experience. Embodied cognition is a theory in cognitive science that emphasizes the role of embodiment, ie, a wide range of bodily processes including sensorimotor and affective processes in cognition.6 According to this theory, cognition emerges from dynamical interactions among the brain, the body, and the environment. Importantly, cognition is dependent on the perception of the “self,” and cognition should be regarded as a developmental process. Initially, sensations give rise to the sense of body ownership, and then actions (internal actions such as interoception or external actions), agency, and language enable individuals to develop a mental representation of their body and a coherent sense of the “self.”7 I would argue that clinical decision-making is influenced by each clinician’s perception of the “self” and that clinical decision-making is dependent on sensorimotor integration, analytical and nonanalytical reasoning, and emotional responses. In addition, clinical decision-making depends on interactions with the patient and with the external environment. In considering this framework, clinicians and students are encouraged to identify how cognitive biases and embodied cognition inform decision-making. Cognitive and Affective Biases and Decision-making Clinical decisions about a patient’s diagnosis and management in osteopathy are likely to be either intuitive or analytical. During the past 3 decades, researchers have significantly advanced our knowledge regarding decision-making processes. Recently, the dual process theory has gained wide acceptance as a model of human reasoning and decision-making.8 This theory divides decision-making into 2 broad and distinct types of processes: intuitive and analytical. Intuitive decision-making, also known as nonanalytical, is characterized as fast, automatic, abstract, and largely unconscious, while analytical decision-making is characterized as slow, deliberate, rule-based, and conscious. Intuitive processes are largely based on pattern recognition, which enables individuals to associate alreadyknown patterns with particular decisions and actions. Reasoning does not occur in the intuitive mode. Instead, cognitive systems simply respond to the perceived pattern.3 Intuitive judgments are highly effective and essential in everyday clinical practice. But they are more likely to fail, and they are more likely to be associated with cognitive and affective biases and diagnostic errors. Therefore removing, or at least mitigating, biases is critical to providing safe and optimal patient care. To date, more than 100 cognitive biases (eg, confirmation bias, halo effect, and anchoring effect) and 12 affective biases (eg, visceral bias and countertransference of both negative and positive feelings toward patients) have been identified. Biases associated with intuitive judgments are largely attributed to innate, hard-wired biases that developed in our evolutionary past, as well as those acquired during our professional development and in our work environments.4 Moreover, factors such as context, fatigue, affective state, cognitive overload, gender, and rationality are likely to predispose clinicians to biases.4 Whereas intuitive judgments have low computational load, analytical decision-making requires a significant amount of attention. Analytical decision-making tends to be slow, and it can interfere with simultaneous thoughts and actions.9 As a consequence, the cognitive system tends to default to the state requiring minimal cognitive effort, ie, intuitive decision-making. 3 Individuals predispositions to resort to heuristics or shortcuts in their decision-making is largely hard-wired. However, expertise in clinical practice is likely to magnify this phenomenon. Experts are particularly prone to confirmation bias because they tend to trust prior decisions and evidence while ignoring new and relevant evidence. In contrast, novices might make the right decision because the problem is unknown to them and, consequently, their judgment is reached using analytical processes primarily. Cognitive and affective debiasing strategies enable clinicians to identify the source of their biases and, ultimately, reduce diagnostic error. Debiasing strategies include developing insight and self-awareness; acquiring metacognitive competencies, such as a critical reflective approach to problem-solving; and adopting cognitive forcing strategies, such as diagnostic checklists.10 Using cognitive and affective debiasing strategies enable clinicians to recognize the sources of bias and ways to manage them. Most important, these strategies will enable clinicians to override inadequate intuitive judgments and improve the quality of the care they provide. Embodiment and Decision-making Palpation lies at the heart of osteopathic diagnosis, care, and professional identity. Although I agree that cognitive systems play a central role in decision-making, I would argue that embodied cognition is central to osteopathic clinical decision-making. In osteopathic diagnosis and care, a definite distinction between perceiver and perceived is absent. During palpation, the haptic sense interacts with other senses to enable clinicians to discern patients’ clinical problems. Importantly, in perception, haptics differ from vision and other senses because we are unable to perceive the world tactilely without perceiving ourselves in the process.11 Haptic perception combines multisensory and motor elements, and it is inescapably intertwined with a sense of body position and movement.11 Therefore, it can be argued that decision-making is influenced by each clinician’s embodied “self” (including elements of body schema, body awareness, and body image) through bodily interactions with a patient and the environment. In support of this viewpoint, Øberg et al6 recently argued that in physical therapy, the bodies of both the clinician and patient should be regarded as bodily agents, which together play an active role in the clinical decisionmaking process. Consequently, clinical decision-making should be regarded partly as an intersubjective bodily practice, not simply as a dialectic of instrumental and narrative practice. The Figure (below) represents the proposed embodied model of clinical decision-making in OMM in which a clinician’s body, internal environment, and neurocognitive systems interact dynamically with the world and a patient’s agency to allow the clinician to reach a diagnosis. 4 Figure.A clinician’s personal experiences, internal environment, and neurocognitive network combined with input to lead the clinician to a diagnosis Professional and personal values Own style of clinical practice Clinical experience Clinician’s body Neurocognitive networks Motor systems Patient presentation Exteroceptive and interoceptive systems External interactions Memory systems Internal environment Signs of dysfunction Internal interactions Dynamic workspace Top-down cognitive processing Perception of the self (osteopath) Diagnosis Sensorimotor integration In OMM, a clinician’s hands are crucial instruments of the mind. As the clinician’s hands explore a patient’s body, they detect areas of dysfunction, and the clinician uses mental imagery to identify problems based on the patterns of dysfunction that are stored in the clinician’s mind. Importantly, mental images used to perceive objects result from changes that occur in the body and brain during physical interaction with the objects.12 It has been proposed that cognitive systems are embodied and that the internal body plays an important role in perception.13 Based on that proposal, cognition emerges from dynamical interactions among the brain, body, and the world, and cognition is largely action oriented. With this in mind, it is likely that an osteopath’s cognitive systems partner with his or her hands to form a functional unit that engages with the agent’s environment. Although some decisions are likely to involve analytical processes, the vast majority are likely to be intuitive. Interestingly, Radman14 proposes that the hands possess an embodied faculty to explore the environment without engaging a conscious thinker. Conclusion Clinical decision-making in OMM is an embodied experience. In particular, the perception of tissue dysfunction is not only generated in the brain but it also emerges from clinicians’ interactions with patients and the environment. This embodied model enables clinicians to understand each patient as a living body actively engaged in the environment rather than as a biological organism that needs to be fixed either by clinicians or in collaboration with the patient.6 Despite what some osteopathic clinicians believe, the majority of their clinical decisions are likely to be based on intuition that arises from pattern recognition. Although intuitive judgments are highly effective and essential in everyday clinical practice, clinical decision-making is prone to cognitive and affective biases. If it is human nature to default to intuitive thinking in which systematic errors are likely to be made, we need to recognize that and mitigate its influence. We have a deliberate “self” that can reflect on who we are and on the 5 existence and dominance of intuitive decision-making processes.15 As a consequence, clinicians should use cognitive and affective debiasing strategies that enable them to mitigate errors and to make more sound decisions. References 1. Seffinger MA. Osteopathic philosophy. In: Ward RC, ed. Foundations for Osteopathic Medicine. Baltimore, MD: Lippincott Williams & Wilkins; 1997; 3-12. 2. Klein G. Intuition at Work. New York, NY: Currency Doubleday. 2003. 3. Croskerry P, Petrie DA, Reilly JB, Tait G. Deciding about fast and slow decisions. Academic Medicine. 2014; 89(2):197-200. doi:10.1097/ACM.0000000000000121. 4. Croskerry P, Singhal G, Mamede, S. Cognitive debiasing 1: origins of bias and theory of debiasing. 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