Objectives If we are to transform the communication of health evidence and risk for informing healthcare decisions, we need to understand how clinical decisions are made in the first place. Over the past five decades, healthcare has become increasingly complex due to an ageing population, changes in the clinician career pathway, regulation, and clinical/information technology. Interestingly, we know little about the impact of these changes on decision-making within dentistry or healthcare in general and how it influences the implementation of evidence into practice. To address this gap, a scoping review was undertaken to identify important factors involved in the decision-making process and review the historical trajectory of the literature to set the future research agenda in this field.
Method This scoping review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework (PRISMA-SR). The bibliographic databases were searched from 1946 to February 2021: Ovid MEDLINE(R), In-Process & Other Non-Indexed Citations from 1946 to present, and Scopus (Elsevier), without language restriction. Inclusion criteria were: ‘decision-making’ had to be in the title. Included studies could be qualitative, quantitative (prospective/retrospective), reviews, or mixed methods studies from peer-reviewed journals. Exclusions were papers focusing on ‘patient-centred decision-making’, as only primary clinical decision-making was explored. The final search results were exported into EndNote, and duplicates were removed. As this was a scoping review risk of bias was not assessed or a protocol registered. The studies were mapped out thematically and analysed to track the historical development of the literature.
Results 105 studies met the inclusion criteria, of which 38 were observational studies. Of the theoretical models described, 46% were descriptive of the decisions made, 17% suggested decision-making improved only with experience, 16% were normative under uncertainty (a purely rational decision-making model based on subjective judgements), and 7% were normative under certainty (based on probabilities). From 1970 to date, theory based on economic models has been replaced by decision-making tools and now data analysis. The three main clinical domains studied were endodontics, cariology and periodontics. The most common outcome measure was inter-assessor agreement, which showed little improvement over the review period with a median kappa of 0.48 (Range: 0.24 to 0.63). Few of the studies had good external validity. Decision-making tools appeared to be developed in a top-down approach, and implementation was lacking. Clinicians’ decisions appear to be driven more by personal experience than clinical evidence.
Conclusions Over 50-years, decision-making in dentistry has moved from conceptual theory-driven papers increasingly towards the provision of data and tools to facilitate the decision-making process. Many of the papers provide information to assist in decision-making but no guidance on how best to translate theoretical ideas into the clinical setting. Though investigators discussed normative and descriptive decision-making models, the most consistent theme was that clinical experience would guide the clinician’s decision-making process to an optimal conclusion. Clinicians’ decisions appear to be driven by ‘treatment scripts’ learned by direct clinical experience early in their training. These ‘treatment scripts’ were quite resistant to changes in the clinical evidence. Clinicians valued technical outcomes over patient-centred outcomes, possibly to avoid accusations of malpractice. Where there was a good application of evidence in the clinical decision-making process, this required a ‘cognitive forcing strategy’ in place to prevent the clinicians from pursuing experientially biased treatment scripts.
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