What Do Physicians Believe About the Way Decisions Are Made? A Pilot Study on Metacognitive Knowledge in the Medical Context

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.


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-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. Researchers 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). The experience of the physicians within each specialty varied between 1 and 34 years and was significantly correlated 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, χ 2 (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 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 characteristics 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).

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 responding 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 differences among the categories of physicians for Item 5 (F(2.53) = 3.79, p < .05, η 2 = .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 according 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.  (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, η 2 = .17). Although the differences 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. The distributions of the categorized responses to the open questions were analyzed with contingency tables and the relative χ 2 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 experience 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 experience (47%) and consultation with others (30%) and can help others to be good decision-makers by setting a 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%). 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 fundamental 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, 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 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 fundamental 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 individuals 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 postdecisional 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 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.

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