Naturalistic Decision Making and the Practice of Health Care

A recent essay in this journal identified health care as a fertile domain for extending the reach of naturalistic decision making (NDM). It targeted the “best practices regimen,” a host of initiatives begun in the late 20th century that address problems in service delivery, skyrocketing costs, and impediments in transforming products of basic science into effective treatments. Of particular importance are efforts to base treatment decisions on empirical research findings and to gauge the quality of decisions by their conformance to evidence-based practices. The challenges that the essay identified and the ways of addressing these challenges are well known in the health care community. They have had limited impact owing to several factors, including how advocates of the best practices regimen envision clinical decision making and their tendency to equate the exercise of skill with resistance to change. This paper describes the regimen’s concept of decision making and its principles and deficiencies. It also identifies a conundrum: oversimplification prevents complexity from being recognized; as a result, evidence-based recommendations frequently have unforeseeable and deleterious consequences. The paper proposes that NDM is well positioned to address these problems and make a valuable contribution to health care practice. It illustrates NDM-based theories and concepts with a research example and describes their ability to address complex issues that arise in treating chronic illnesses.