Do FORDEC – Decision Making as a Resident Doctor

So, what role does it have in medicine?

During foundation teaching, a consultant orthopaedic surgeon introduced us to FOR-DEC: Facts. Options. Risks. Decision. Execute. Check.

“Everyone should know about this,” I thought. Hence this submission.

I also wanted to add my own section to FOR-DEC which is Desired Outcome (Do).

We make thousands of decisions every day. Most happen on autopilot (see what I did there?). When should I blink? Which hand should I hold my toothbrush in? Most people don’t think about those things (I said most).

Clinical decisions are no different. Most are fast and some are slow…

Ideally, we’d make good decisions that lead to good outcomes. However medicine isn’t always that simple. Good decisions can still result in bad outcomes given that illness can be unpredictable. Equally, bad decisions occasionally have good outcomes. Gambling your life savings in the lottery could lead to becoming a millionaire but that’s luck rather than good judgement. We want to avoid sitting in the bad decision, bad outcome bin.

DOing FOR-DEC doesn’t guarantee the right outcome. It provides a framework to make thoughtful, defensible decisions, reduce cognitive load, and communicate your reasoning when it matters.

As you read through each step, think about situations you’ve encountered that could have benefited from a more structured approach.

Facts

What is the problem? What do I know to be true? What information is missing?

Clearly defining the problem is often harder than solving it. Slow down long enough to gather the facts that matter.

Imagine a patient has a blood pressure of 90/50. Before acting, what would you need to find out? Perhaps:

• Is this normal for them?
• What is their NEWS score?
• Are they symptomatic?
• Are they bleeding or septic?
• What medications are they taking? and so on…

Options

What are the possible solutions? What guidance exists? Who else could help generate ideas?

A patient needs IV access but they have difficult veins. Do you try again? Attempt with an ultrasound? Ask a senior? Call anaesthetics? Keep hoping the cannula gods intervene?

Discussing the case with another foundation doctor or a senior often uncovers possibilities you hadn’t considered. The multidisciplinary team frequently knows what is practical as well as what is clinically appropriate and you don’t settle on the first solution that comes to mind.

Experience broadens the options you consider, but you don’t have to do it alone.

Risks (and benefits)

What are the risks and benefits of each option? What could go wrong? How likely is it?

Every option carries risk, including doing nothing. Try to quantify the risk where you can.

If time allows, use a risk matrix; think about both impact and likelihood. Which complications are catastrophic? Which are common? Which can be prevented or mitigated?

I once reviewed a patient with cancer whose leg ultrasound was negative for DVT. They later developed painful, erythematous swelling. Cellulitis seemed the obvious diagnosis, but the experience of a senior prompted repeat imaging, which demonstrated an extensive superficial venous thrombus requiring treatment equivalent to a DVT.

The risk perception changed based on experience and knowledge.

Desired outcome

Before making a decision, ask yourself: what outcome am I actually trying to achieve?

This step could fit at the beginning of FOR-DEC as well as underpin every step before the decision as it shapes the final outcome.

Your desired outcome should focus on the patient’s best interests and not simply the quickest or easiest solution.

It’s also worth recognising your own biases. Are you more inclined to rush because it’s the end of your shift? Are you avoiding asking for senior help because you don’t want to appear incompetent (I continue to work on this)? Are you trying to appease every member of the team?

Being aware of these influences doesn’t eliminate bias, but it helps prevent them driving your decisions.

Finally, sense-check your desired outcome against the four ethical principles:

• Beneficence – Does this benefit the patient?
• Non-maleficence – Am I minimising harm? Justice – Is this fair and appropriate use of healthcare resources?
• Autonomy – Have I respected the patient’s wishes? (they’re the main character after all). 

Decision

What am I going to do?

Sometimes new information means revisiting the Desired Outcome, Facts, Options or Risks.

What isn’t helpful is becoming trapped in an endless FOR-FOR-FOR loop as indecision and inaction is still a decision.

I once prescribed rectal midazolam for a patient with ongoing generalised jerking movements. The seizure stopped, and I followed guidance by checking observations, giving oxygen and taking bloods including a gas.

What I missed was a crucial fact: the seizure had already lasted more than five minutes before I arrived. The correct decision had been to call the crash team immediately.

The quality of your decision depends on the quality of the information you start with.

Execute

Who needs to do what? Who needs to know? When should it happen?

A good decision has little value if it isn’t acted upon promptly and communicated clearly.

It’s a great prompt when nursing staff ask ‘What’s the plan?’ however daunting it may be.

Check

Has the situation changed? Is the plan working? Does anything need to be revised?

Decision-making doesn’t stop once the plan is implemented. Patients deteriorate. Investigations return. New information emerges.

Checking is an ongoing process and allows you to recognise when your original decision remains appropriate as well as when it needs to change.

• Is the patient now normotensive? 
• Has a cannula been inserted?
• Did the patient get prescribed their anticoagulant?
• What is the lactate on the VBG?  and so on…

DOing FOR-DEC won’t prevent every bad outcome. Medicine is too uncertain for that. But it will help you make more thoughtful, transparent and defensible decisions.

And if you’re ever asked to justify why you acted as you did (to the GMC or anyone), you’ll have a structured reasoning process to stand behind.

Credit to Mr Duffy for an excellent presentation that introduced me to FOR-DEC and for allowing me to write about it as part of the UKFPO project.

Obatobi Akinlolu

F2, Yorkshire and Humber Foundation School

September 2026

All previous HOFP articles can be found on on our HOFP webpage

The views expressed in this article are those of the author’s, and do not necessarily reflect the official stance of the UKFPO.