Clinical Reasoning and Decision Making Flashcards
What are the contextual factors in our decision making?
- People
- Places
- Time
- Pressures
The ‘ideal’ or normative approach
- Establish the chief complaint(s)
- Develop a differential diagnosis
- Perform a history and physical examination
- Order laboratory or imaging studies
- Establish a provisional diagnosis(es)
- Implement a management plan
Establishing chief complaint(s)
First or repeat interaction?
* How long does the patient get to talk before being interrupted?
* Who leads the conversation?
* Is there always a simple “chief complaint”?
Differential Diagnosis
Developing a list of the possible conditions that might produce the presenting symptoms and signs.
* Symptoms are described by the person/carers (subjective)
* Signs are what can be measured (objective)
A differential diagnosis ensures that you do not accidently exclude possibilities by jumping to conclusions (it is a runny nose therefore it is just a cold).
History and examination
- Interview
- Records (history)
- Physical examination
- Psychological evaluation
- Office tests
- Laboratory tests
- Medical Imaging
- Surgical procedures
Provisional Diagnosis and Management Plan
Provisional diagnosis is the most likely condition according to the given evidence.
The Management Plan is based on more than the diagnosis, it must accommodate:
* Person centred care
* Access to services
* The biopsychosocial approach
The Clinical Reasoning Cycle
- Clinical reasoning is on ongoing cycle
- You don’t necessarily go in a simple circle, but may go back
before you go forward
How we decide
System One
Intuitive
System Two
Analytical
System One: Intuitive Decision Making
Pattern recognition
* “Gut feeling”
* Fast
* Almost at an unconscious level
* Used by experts rather than novices
* Tends to increase in accuracy with contextual experience
System One: Intuitive Decision Making cont.
Selecting a response based on: identification of a previously known outcome
weighing some inputs over others (determining importance)
personal bias and professional expertise
Heuristics
shortcuts or rule of thumb
Used to look for patterns
When intuitive decision making is used, we look for mental shortcuts
The more experienced, the more shortcuts we create
Shortcuts give quick results BUT
- can jump to conclusions
- ignore additional evidence
Problems with Intuitive Decision Making
Flawed information
* Intuitive decision making will respond quickly to inaccurate, insufficient, unreliable, or incomplete information based on patterns from previous experiences.
Short term emotional bias
* Cognitive research has shown that even experts’ decisions are influenced by unrelated emotions during the time of making a decision.
Problems with Intuitive Decision Making cont.
Insufficient consideration of alternatives
* Intuition generally relies on pattern recognition and will point to solutions that have worked well with the current perceived pattern. This will limit considered options even though you may be dealing with a new decision situation that might
require a novel or unique solution.
Prejudices
* Emotions help form our intuition and can allow
flawed experiences to overrule sound facts and evidence.
Problems with Intuitive Decision Making cont.
Lack of openness
* Every person has a different experience base that provides the platform for their intuitions.
Given that one’s intuition is not easily explained, it is difficult to use intuition in a group context.
Inappropriate application
* People that have good experience, expertise, and intuition in one area can become overconfident and apply their intuition in an unfamiliar or unrelated area.
System Two Analytical
Using logic and a methodical procedure
* Conscious
* Deliberate
* Slower
* Can be more reliable
Example - Algorithmic
- Classical decision tree approach
- Methodical
- Slow
- Each decision within the approach is carefully made
- Particularly suitable for novices
Hypothetico-deductive
Testing hypotheses, and deducing answers from information
Commonly used in Crime Solutions
Slow but accurate
* The Butler is the murderer
* Collect clues, analyse and test hypothesis (the Butler has an
alibi)
* New hypothesis, the evil Step-Mother is the murderer
* Collect clues, analyse and test hypothesis (the Step-Mother
will inherit a fortune but she is paralysed)
* Repeat until decision made
Problems with Analytical Decision Making
- Slow
- Resource intensive
- Not always appropriate (e.g., in an Emergency)
- Mistakes still happen:
- Following the wrong line of reasoning
- Cognitive overload (too much in your head to think clearly)
- Fatigue/sleep deprivation
Intuitive versus analytical
- Neither is perfect
- No person will use the same approach in all
circumstances - Intuition favours the expert in simple decisions
- Analysis favours the novice, and in all complex
decisions - Even careful analytical decision making can go astray
Factors in decision making
Who is making the decision?
* Are they novices or experts?
* Do they bring particular emotions,
cultural issues or cognitive
approaches to the circumstance?
Factors in decision making cont.
Who is involved in the decision making?
* Individual (easier to use System One)
* Team/Group (justification of decisions
needs System Two)
* Patient, family, friends (collaborative
decision)
Factors in decision making cont.
What are the contextual factors?
* Communication and information
* Participation of others
* Physical, social and emotional environment
* Previous experiences
Factors in decision making cont.
What are the circumstances?
* Are there time pressures?
* Are there resource issues?
* Where is the decision maker in the hierarchy?
* Is there organisational interference?
Common mistakes in decision making
Overconfidence error:
Dunning - Kruger Effect
Unskilled and unaware of it: lack of awareness of own shortcomings and incompetence lead to inflated self-assessments
- A belief that you have greater knowledge and skills than
you actually have, and thus believing your decisions are
more likely to be correct
Confirmation bias
- We look for evidence to support and confirm our decisions
- For example – only seeking evidence that backs up your opinion
Affective Bias/ Attribution Error
- Including your own feelings and beliefs, such as cultural assumptions, to the detriment of clear decision making
- Affective bias might cause you to treat a person you dislike differently to a person you like
- A fundamental attribution error would be to make the assumption that an obese person is lazy, an Indigenous person is an alcoholic
