B P1 C5 Clinical Decision-Making in Cardiology Flashcards
Most of medical decision-making, however, lies outside of simple algorithms and requires judgment.
There are two major settings, related to diagnosis and treatment, where clinical reasoning is critical:
(1) Decisions about classifying an individual who presents with symptoms or signs of disease into the proper diagnostic category
(2) Decisions about treatments. These decisions are also challenging because they involve weighing risks and benefits, speculating about estimates for these parameters, and aligning choices with the preferences of the patient.
_____ is an important application of probabilit and is often used to estimate patient risk and assist in decision-making.
This approach generally uses the results of statistical models that have identified prognostic factors and incorporated them into a tool that may assist clinicians. In recent years, many tools have been developed to assist in the rapid assessment of patients.
Risk stratification
The terms “true positive rate” (TPR) for _____ and “true negative rate” (TNR) for _____ are alternative labels
TPR: Sensitivity
TNR: Specificity
A clinician wants to know the probability that a positive test result is truly positive, or the _____, and also the probability of disease given a negative test result, which is 1 minus the negative predictive value (NPV).
Positive predictive value (PPV)
A _____ ratio is defined as the percentage of patients with a disease who have a given test result divided by the percentage of patients without disease who have that same test result.
Likelihood ratio
A positive likelihood ratio is the percentage of patients with disease with a positive test result divided by the percentage of patients without disease with a positive test result
Formula:
PLR: (TPR/FPR,or sensitivity/[1 − specificity])
A negative likelihood ratio is the percentage of patients with disease with a negative test result divided by the percentage of patients without disease with a negative test result
Formula:
NLR: (FNR/ TNR, or [1 − sensitivity]/specificity).
Tests that are highly ______ are better for ruling in a diagnosis
Specific
“SpPin”
(Highly specific tests, if positive, are good for ruling in.)
Tests that are highly _____ are better for ruling out a diagnosis
Sensitive
“SnNout”
(Highly sensitive tests,if negative,are good for ruling out.)
Cognitive psychologists describe two general thinking modes that people use to make decisions:
System 1 thinking is highly intuitive and fast, but prone to jumping to conclusions.
System 2 thinking is analytical and logical, but slow, effortful, and has difficulty with uncertainty.
Cardiology decisions require both thinking modes, and expert clinicians are able to use a balance of intuition and analytical thinking to make optimal decisions.
Calibrating intuitive thinking and organizing thinking by thoughtfully monitoring clinical decisions (so called “meta-cognition”) are key to good clinical practice.
Some psychologists describe three general types of fallacies:
(1) Hasty judgments
(2) Biased judgments
(3) Distorted probability estimates
_____ judgments occur when System 1 thinking is unmonitored.
For example, premature closure of a diagnostic exercise, with- out the use of a differential diagnosis, or becoming anchored on a diagnosis can lead to a misdiagnosis
Hasty judgements
_____ judgments occur when unconscious thoughts influence ideas, emotions, and actions.
This can take the form of priming, stereotyping, overconfidence, risk aversion, or dread. Emotions can have a halo effect, influencing clinical thinking in imperceptible ways. Exaggerated fear of malpractice, financial incentives, and conflict of interest can adversely affect decisions.
Biased judgements
