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Amy, a relatively new internal medicine specialist treated a patient who exhibited a set of symptoms typical of a fairly common condition: rash, reported localized mild pain, headache, 102 °F temperature, and chills. A localized skin discoloration near the rash was not considered exceptional or unusual (“just a bruise from a bump”), and a quick glance at the chart of the patient’s history revealed nothing exceptional. Amy, already behind on her appointments, quickly and confidently decided, “that’s flambitis” (a condition that was the subject of a recent invited medical seminar at the hospital), prescribed the standard antibiotics and dismissed the patient. A day later the patient phoned the nurse to complain that the symptoms had not disappeared, but Amy, reading the message, instructed the nurse to call back and say that it would take some time for the medicine to take effect, and not to worry. Yet another 24 hours later, the patient appeared at the ER, with a temperature now of 104 °F, and more intense pain. Amy was called in and a careful inspection revealed that the slight discoloration had darkened, and a prior condition in the medical chart had been overlooked in Amy’s quick scan. These two newly appreciated symptoms or cues suggested that flambitis was not the cause, and led Amy to do a rapid, but intense and thoughtful, search of the medical literature to obtain reasonable evidence that the condition was a much less prevalent one called stabulitus. This was consistent with an earlier report in the patient’s medical record that Amy, in her quick glance, had overlooked. Further research suggested a very different medication. After making that prescription, Amy now started monitoring the patient very closely and frequently, until she observed that, indeed, the symptoms were now diminished. Following this close call of a misdiagnosis and the resulting poor decision on treatment, the first serious decision error since her licensing, Amy vowed to double check her immediate instincts, no matter how much the symptoms looked like a common condition, to more thoroughly check the medical history, and to follow up on the patient’s condition after the initial treatment. Although this scenario happened to occur in the medical domain, each day people make many decisions in situations that range from piloting an aircraft and voting for a candidate to financial planning and shopping. Some of these decisions have life and death implications and other times a poor choice is just a minor annoyance. Generally, these decisions depend on understanding the situation by integrating multiple sources of information, determining what the information represents, and selecting the best course of action. This course of action might be simply dropping an item into your shopping cart or it might require a plan that coordinates other activities and people. This chapter builds on the previous chapter’s description of cognition. The elemental information processing stages of selective attention, perception, working memory, long-term memory, and mental workload all contribute to decision making. These 7.1 Macrocognitive Environment 203 concepts form the building blocks of cognition and can be thought of as elements of microcognition. In contrast, this chapter describes decision making in the context of macrocognition, or the high-level mental processes that build on the stages of information processing, which include situation awareness, decision making, problem solving, and metacognition. Macrocognition is defined by high-level processes that help people negotiate complex situations that are characterized by ambiguous goals, interactions over time, coordination with multiple people, and imperfect feedback.

Figure 7.1 highlights five elements of macrocognition, with the elements arrayed in a circle roughly in the order they might occur, but in reality, the process is more complex with all processes being linked to all other processes and occurring in a repeated cycle. At the center is metacognition—thinking about one’s own thinking—which guides the individual macrocognitive processes. Microcognition and macrocognition offer complementary perspectives that suggest different ways to enhance safety, performance, and satisfaction.