Clinical reasoning and critical thinking Flashcards
Development of medical expertise
- Stage 1. Elaborated causal networks–Facts and relationships–Causal models of disease processes
- Stage 2. Abridged networks–Starts when exposed to real patients–Simplified causal models, with associated signs, symptoms, diagnostic labels–Short-cuts emerge
- Stage 3. Illness scripts–Based on repeated experience of real patients–Information in context with temporal relationships–Key features–Specification of what to do
- Stage 4.Instance scripts–Based on long experience–New patients are recognized as:•“similar to patient X”•“treated as patient X was treated
Novices use cumbersome search methods
Experts recognise patterns and are purposive
Confirmation bias
- Seek evidence supporting a belief
- No data that tests competitors
- Ambiguous evidence interpreted as supporting favoured hypothesis
- How do we decide what evidence to consider?
Anchoring and insufficient adjustment
- How should we make probability estimates when information comes in one piece at a time?–Ideally, base accurate estimate on initial info–Adjust estimate appropriately based on new info
- Frequently, the process has two flaws–Inaccurate initial estimate–Insufficient weight given to the new information–Hence the finalprobability estimate depends too much on the initialestimate
Availbility
- Probability estimates affected by factors other than frequency
- Ease of recall
- Saliency
Cognitive strategies
Avoiding perceptual biases
•Reframe decisions and consider multiple descriptions and reference points
Avoiding associative errors
•Search for neglected information
•Search for information contrary to the proposition
Support better reasoning strategies
•Evaluate decision processes not outcomes
•Ask yourself some simple questions:
–What else could it be ?
–Is there anything that doesn’t fit?
–What can’t we explain?
–What are you most worried about ?
–Could the patient have more than one problem
Decision trap 1
Decision trap # 1Plunging in Beginning to gather information and reach conclusions without thinking about the crux of the issue or how decision like this should be made #1 Metadecision questions •What is the crux issue ? •How does this decision affect others ? •Is now the right time ? •What does the past tell us about ? A Framework for Problem Solving •Pr.......the problem •O........the objectives •A........the alternatives •C........the consequences •T........the tradeoffs •I.........Integrate and link •Ve......Value and evaluate
2- Challenging your frame
# 2 Challenging your frame •Boundaries •Reference points •Yardsticks •Analogy •Seek others’ opinion •Role play your adversary •Welcome diversity •Alternative metaphors
Decision trap 3
Overconfidence in your judgment
Failing to collect key factual information because you are too sure of your assumptions and opinions
Faulty heuristics
•bias in favour of recent evidence, availability and vividness
•anchoring bias
3 Avoiding the trap •Have the discipline to seek information that might disconfirm your opinions
How to gather intelligence well
- Insist that people state estimates in terms of ranges and levels of confidence
- Create feedback, training and accountability
- Ask disconfirming questions
- Use prospective hindsight
Decision trap 4- shortsighted shortcuts: relying on inappropriate rules of thumb
Shooting from the hip
•Believing that you can keep straight in your head all the information you’ve discovered and “wing it”, rather than following a systematic procedure.
Avoiding the trap
•The right rules of thumb
•Eg. Overestimate by 20% the amount of time it will take to accomplish a plan and underestimate the expected results
•Benjamin Franklin’s linear model
•“Pros” and “Cons” chart
•Higher level multi-attribute models eg the Analytic Hierarchy Process
Decision trap 5- group failure
Decision trap # 5Group failure
•Assuming that with many smart people involved, good choices will follow, and therefore failing to manage the group decision making process.
Symptoms of group think •illusion of invulnerability •stereotyping of opponents •pressure on dissenters •shared illusion of unanimity •self censorship of deviations from apparent group consensus
# 5 Avoiding the trap •Leaders avoid stating their own opinions early in deliberation •Avoid premature consensus but be critical of ideas not people •Appoint a devil’s advocate •Separate factual issues from value issues
The benefits of MD team conferences
The benefits of multidisciplinary team conferences
•More effective sharing of information
•Collective wisdom
•Better coordination of services
•Making and retaining a record of decision process
•Provision of feedback on previous decisions
Decision trap 6- fooling yourself about feedback
Decision trap # 6Fooling yourself about feedback
Failing to interpret the evidence from past outcomes for what it really says (ego and hindsight bias)
Clinicians seldom get comprehensive feedback on positive and negative outcomes- Verification bias
Past predictions are are mistakenly recalled as overly consistent with actual outcomes- Hindsight bias
Exposure to skewed non-representative populations
Avoiding the trap
•When you succeed, honestly consider your contribution
•When you fail, avoid rationalization
•Keep prospective records of the reasons why actions were taken
•Thereby, reflect on learning points
Critical thinking tools
Critical thinking tools •Judge judiciously •Question the questionable •Chase the challenges •Consider the alternatives fully •Use a method •Take various viewpoints •Sideline the self
