2b Clinical Decision Making

Question 1

Describe the effect of extraneous factors on clinical decision-making using an example.

Answer 1

Junior-senior relationship may lead to the wrong decision being made

Question 2

What is Confirmatory Bias?

Answer 2

The tendency to search for or interpret information in a way that confirms one’s preconceptions, often leading to errors

Question 3

What is the Sunk Cost Fallacy?

Answer 3

Rationally, the only factor affecting future action should be future cost/benefit ratio BUT humans do not always act rationally
Often, the more we have invested in the past, the more we are prepared to invest in a problem in the future

Question 4

State some strategies for improving clinical decision-making.

Answer 4

 Recognise that heuristics and biases may be affecting our judgement even though we may not be conscious of them
 Counteract the effect of top-down processing by generating alternative theories and looking for evidence to support them rather than just looking for evidence that confirms our preferred theory (confirmatory bias)
 Understand and employ statistical principles e.g. Bayes’theorem
 Use of algorithms and decision support systems

Question 5

How is clinical decision making done?

Answer 5

Intuitive understanding of probabilities is combined with cognitive processes (heuristics) to guide clinical judegement
- Heuristics: rules of thumb, educated guesses, mental shortcuts

Question 6

What are the “hot” and “cold” systems for decision making? (Kahneman’s)

Answer 6

Hot (aka intuition):

• Emotional
• Simple
• Reflexive, fast
• Accentuated by stress
• Stimulus control

Cold (aka rational):

• Cognitive
• Complex
• Reflective, slow
• Develops late
• Attenuated by stress
• Self control

Question 7

What is Representativeness Heuristic?

Answer 7

Subjective probability that a stimulus belongs to a particular class based on how 'typical' of that class it appears to be (REGARDLESS of base rate probability)
e.g. 60 year old women with no characteristic symptoms of MI; cannot rule out possibility of MI

Question 8

What is the Availability Heuristic?

Answer 8

• Probabilities are estimated on the basis of how easily/vividly they can be called to mind
  e. g. people tend to heavily weigh their judgements towards more recent information

Question 9

Give an example for availability errors by clinicians?

Answer 9

Clinician who recently missed a diagnosis in a patient might overestimate the risk in similar patients (despite very small probability of disease)

Question 10

How can we reduce cognitive errors and heuristics in clinical decision making?

Answer 10

1. Education and training - integrate teaching about cognitive error and diagnostic error into medical school curriculum
2. Feedback - audits, followup patients
3. Accountability - establish clear accountability and followup
4. Generating alternatives - encourage differential diagnosis
5. Consultation - Seek 2nd opinions
   Use ALGORITHMS
   Use Clinical decision making support systems