2: Clinical Decision making

Question 1

What is an error?

Answer 1

the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).

Question 2

Name examples of medical errors

Answer 2

• incorrect diagnosis
• failure to employ indicated tests
• error in the performance of an operation, procedure, or test,
• error in the dose or method of using a drug.

Question 3

Explain the role of medication errors in the NHS

Answer 3

It has big effects

• estimated to account for 12000 deaths per year
• and £ 0.75-1.5 billion additional costs per year

Question 4

What are the causes for diagnostic errors?

Answer 4

Are the largest errors occuring in the health care system

Question 5

What are the “two systems” in clinical decision making?

Answer 5

There is a “hot” and a “cold” system in clinical decision making

Question 6

Explain the characteristics of the “hot” system in clinical decision making

Answer 6

Question 7

Explain the characteristics of the cold system in clinical decision making

Answer 7

Question 8

What are heuristics?

What is their role in clinical decision making?

Answer 8

Heuristics are often refered to a rule of thumb due to prior experiences

• Heuristics usually involve pattern recognition and rely on a subconscious integration of patient data with prior experience

Question 9

What is confirmatory bias in medical decision making?

What is a way to prevent this?

Answer 9

The tendency to search for or seek, interpret, and recall information in a way that confirms one’s preexisting beliefs or hypotheses, often leading to errors

–> Can be prevented by making differential diagnosis

Question 10

What is the role of overconfidence in medicine?

Answer 10

Often clinicians are overconfident concerning a diagnosis

• doctors reporterd “completely certain” of why a patient died were wrong 40% of the time

Question 11

Explain the role of sunk cost fallcy in clinical decision making

Answer 11

• already invested time and money makes it less likely to step back from a diagnosis/ procedure etc.

Question 12

Explain anchoring and the role of anchoring effect in clinical decision making

Answer 12

a cognitive bias that describes the common human tendency to rely too heavily on the first piece of information offered (the “anchor”) when making decisions.

–> might lead to ignoring further informations in making a diagnosis

Question 13

What is representative heuristic?

Answer 13

It is used when we judge the probability that an object or event A belongs to class B by looking at the degree to which A resembles B. When we do this, we neglect information about the general probability of B occurring (its base rate)

• E.g: Bob loves classical music, plays chess when growing up and playes golf. What is more likely?
  
  • A= he is a classical trumpet player
  • B= he is a farmer
    
    • Many would choose A because of steriotype but B is just a lot more likely in the population

Might lead to neglect of basic information

Question 14

What are Representativeness errors?

Answer 14

Example:

• A 60-yr-old woman who has no known medical problems and who now looks and feels well reports experiencing symptoms earlier of feeling short of breath, sweaty and clammy, feeling sick, and feeling faint.
• This does not match the typical profile of an MI, which is typically characterised by chest pain.
  
  • Error–> sent her home
• BUT, it would be unwise to dismiss that possibility because MI is common among women of that age and has highly variable presentations

Question 15

Explain the role of framing and age

Answer 15

Overall: older patients are more suspectible to framing and are more likely to agree on a treatment option when framed positively

Question 16

Explaitn the availabilty heuristic

Answer 16

People are more likely to

• overestimate the probability of a catastrophic (but unlikely) event
• overestimate the probability of a more recent event to occur again

–> easier, vivid recall of information

Question 17

Explain how cognitive errors and heuristics in clinical decision making can be imprved?

Answer 17

1. Education and Training
   
   1. teach in med school
   2. Recognise that heuristics and biases may be affecting our judgement even though we may not be conscious of them
2. Feedback
   
   • Increase number of autopsies Conduct regular and systematic audits Follow-up patients
3. Accountability
   
   • Establish clear accountability and follow-up for decisions made
4. Generating alternatives
   
   • Establish forced consideration of alternative possibilities e.g., the generation and working through of a differential diagnosis. Encourage routinely asking the question: What else might this be?
5. Consultation
   
   • Seek second opinions
6. Use of algorithms
   
   • Use of clinical decision making support systems

Question 18

Explain the role and importance of algorythms in clinical decision making

Answer 18

They can be used to limit heuristics and individual errors in clinical decision making

• often based on probability
• An algorithm is a procedure which, if followed exactly, will provide the most likely answer based on the evidence.
• where everything is well defined –> very usefull, but that is not the real life situation