Clinical Decision Making

Question 1

What is to blame for common medical errors?

Answer 1

System-related AND cognitive factors

cognitive ranked higher

Question 2

Define confirmation bias

Answer 2

Tendency to search or interpret information in a way which confirms one’s own perconceptions

Question 3

Define sunk cost

Answer 3

Any costs that have been spent on a project that are irretrievable ranging including anything from money spent from building a house to expensive drugs

Question 4

Explain the sunk cost fallacy

Answer 4

The only factor affecting future action should be the future cost/benefits ratio

BUT

humans do not always act rationally and often the more we have invested in the past, the more we are prepared to invest in a problem in the future – the “Sunk Cost Fallacy” or “Concorde effect”.

Question 5

Define anchoring

Answer 5

A psychological heuristic that influences the way people intuitively assess probabilities

Heuristic = cognitive shortcut that may result in a suboptimal outcome

Question 6

Explain anchoring & adjustment

Answer 6

Per this heuristic, people start with the implicitly suggested reference point (the “anchor”) and adjust it to reach their estimate (adjustments)

o I.E. A price of an item says “Reduced from £100 to £50” then we think this is a great deal (even if it’s not worth £50) as the anchor is £100

Question 7

Define Gambler’s Fallacy

Answer 7

A logical fallacy involving the mistaken belief that past events will affect future events when dealing with random activities, such as with gambling games

Question 8

Framing effect on clinical decision making?

Answer 8

Framing effect – When presented with treatment descriptions, described in positive, negative or neutral terms:
o Older adults – more likely to agree to treatment described in positive terms as opposed to neutrally or negative

Question 9

Define heuristics

Answer 9

Rules of thumb, educated guesses, mental shortcuts
i.e. fast & frugal approaches to thinking

Involves
• pattern recognition
AND
• subconscious integration of patient data with prior experience

Question 10

2 types of heuristics

Answer 10

Representativeness

Availability

Question 11

Representativeness heuristic?

Answer 11

The subjective probability that a stimulus belongs to a certain class based on how ‘typical’ of that class it appears to be regardless of the base rate probability.

• e.g. fit and young 60yo man with vague chest pain that goes away. You should NOT dismiss him in case of MI as its common in that age category

Question 12

Availability heuristic?

Answer 12

Probabilities are estimated based on how easily and/or vividly they can be called to mind.

• e.g. the patient has whatever your last patient who looked like this had

Question 13

What is Bayes’ theorem and what is it used for?

Answer 13

It is a theorem that measures conditional probability

It is used in screening that involves false positives and false negatives such as mammograms/breast cancer

Question 14

How can decision making be improved?

Answer 14

1) Education and Training
• Integrate teaching about cognitive error and diagnostic error into medical school curricula
• 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
• Use of algorithms
• Use of clinical decision making support systems

Question 15

Define algorithm

Answer 15

A logical series of steps to take to decide most effectively, but not necessarily most efficiently