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Clinical Reasoning > CM- Clinical Reasoning > Flashcards

CM- Clinical Reasoning Flashcards

1
Q

What is the hypothetico-deductive model of clinical reasoning?
What are the pros and cons?

A

It is when the physician makes a hypothesis early on and then gathers more information to test the hypothesis which confirms, makes more/less likely or refutes.

Pros: makes sense; can translate to computer algorithm

Cons: used the same by experts and novices, but the experts are more accurate so it doesn’t help us understand how to optimize or teach diagnostic accuracy

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2
Q

Describe the mental representation model for clinical reasoning.

A

Organization of knowledge in formats or representations was used over factual knowledge.

  • application of basic science concepts
  • pattern recognition
  • Bayesian inference
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3
Q

Describe the dual process theory of clinical reasoning.

A

It synthesizes prior research and suggests that clinical reasoning is 2 processes:

  1. System 1 - intuition
  2. System 2 - analytical
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4
Q

How do system 1 and 2 of the dual process theory differ in terms of:

  1. cognitive style
  2. awareness
  3. automaticity
  4. rate
  5. effort
  6. emotional component
  7. scientific rigor
  8. errors
A

System 1 is:

  1. heuristic [rules of thumb]
  2. low awareness
  3. high automaticity
  4. fast
  5. low effort
  6. high emotional component
  7. low scientific rigor
  8. more errors

System 2 is:

  1. systematic
  2. high awareness
  3. low automaticity
  4. slow rate
  5. high effort
  6. low emotion
  7. high scientific rigor
  8. less errors
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5
Q

What are the 5 sources of emotional influence on clinical reasoning?

A
  1. countertransference
  2. fundamental attribution error
  3. ambient, chronobiological, other influences
  4. Endogenous affective disorders within the physician
    - depressive, anxiety, manic
  5. emotional dysregulation of the physician
    - unconscious defenses, avoidance, anxiety
    - excessive emotional involvement or detachment
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6
Q

What is search satisficing?

Is it considered to be system 1 or 2 in the DPT?

A

It states that it is imperative to:

  1. search through uncertainty
  2. need to find a diagnosis, but terminate search at an appropriate endpoint
  3. not agonize over options

It is system 1: heuristic thought that is fast, but error prone

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7
Q

What are the 2 parts of “system 2” in the dual process theory of cognitive reasoning?

A
  1. algorithmic, slow-thinking, computational part

2. rational part that protects against cognitive error

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8
Q

How do system 1 and system 2 differ in their abilities to understand statistics?

A

Both systems poorly understand statistics

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9
Q

What areas of the brain show MRI activity for system 1?

A
  1. right inferior prefrontal cortex

2. hippocampus [sometimes]

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10
Q

What areas of the brain show MRI activity for system 2?

A
  1. ant. cingulate
  2. ventral medial prefrontal cortex
  3. medial temporal lobe

[same areas that get affected with sleep deprivation]

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11
Q

What is executive control?

What is dysrationalia?

A

Executive control is when system 2 overrides system 1

Dysrationalia is when system 1 overrides system 2

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12
Q

What are the 4 types of errors?

A
  1. Diagnostic [17%]
  2. Treatment [44%]
  3. Preventative [12%]
  4. Other
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13
Q

What are 4 diagnostic errors?

A
  1. error/delay in diagnosis
  2. failure to employ indicated tests
  3. outmoded tests or therapy
  4. failure to act on monitoring or tests
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14
Q

What are 4 treatment errors?

A
  1. error in the performance of operation, procedure or test
  2. error in giving treatment
  3. error in dose or method of giving drug
  4. avoidable delay in treatment
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15
Q

What are the 3 main categories of error?

A
  1. no fault [7 percent]
    - masked or unusual presentation of disease
    - patient was deceptive or uncooperative
  2. systemic [65%]
  3. cognitive [74%]
    - 14 percent from incomplete info gathering
    - 83 percent due to faulty clinical reasoning
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16
Q

What type of error is more likely to result in patient harm than other adverse errors?
What type of error is more likely to be multifactorial and preventable?

A

Diagnostic error

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17
Q

What are 5 steps for improving error rates?

A
  1. raise awareness
    - cognitive biases/errors
    - approaches to improve diagnostic accuracy
  2. coach to improve the rate of
    - systemic errors
    - cognitive erros [incomplete data gathering, knowledge deficiencies, test interpretation]
  3. improve ambient conditions
  4. reduce cognitive load
  5. cognitive debiasing
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18
Q

What are Croskerry’s 5 steps for cognitive debiasing?

A
  1. obtain your own complete medical history
  2. perform a focused PE
  3. generate initial hypotheses and differentiate with Hx, PE, and diagnostic testing
  4. Pause to reflect
  5. Embark on a plan, but acknowledge uncertainty and ensure follow-up pathways
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19
Q

A physician locks onto salient features of a patients initial presentation very early in the diagnostic process. He fails to adjust this initial presentation even in light of later information.
What cognitive bias is this?
What OTHER bias can it be severely compounded by?

A

Anchoring bias

-it can be severely compounded by confirmation bias

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20
Q

In what cognitive bias might a physician judge things as being more likely, or frequently occurring, if they readily come to mind?

A

Availability bias

  • recent experience may inflate the likelihood of it being diagnosed; diseases rarely seen are underdiagnosed
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21
Q

Describe base-rate neglect.

A

It is the tendency to ignore the true prevalence of a disease [inflate or reduce the base rate] distorting Bayesian thinking.

*sometimes physicians consciously inflate a disease likelihood to avoid missing a rare but significant diagnosis

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22
Q

What is confirmation bias?

A

The physician looks at confirming evidence to support the original hypothesis, rather than looking for disconfirming evidence to refute it

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23
Q

What is diagnostic momentum?

A

Once a diagnostic label is attached to a patient, it becomes stickier. Intermediaries [nurses, patient, physicians] who should have started with information gathering will make the attached diagnosis definitive and rule out other possibilities

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24
Q

What is fundamental attribution error?

A

Tendency to be judgmental and blame patients for their illness [dispositional cause] instead of examining the circumstances [situational factors]

-marginalized, minorities, psych patients

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25
Q

Describe gambler’s fallacy.

A

The faulty belief that if heads is tossed 10 times, the next toss has a greater probability of tails.

This is like seeing 10 acute coronary syndromes in a row and assuming the sequence will not continue

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26
Q

Describe “playing the odds”.

What other cognitive bias is it diametrically opposed to?

A

In equivocal or ambiguous presentations, opt for the benign diagnosis on the basis that it is MORE LIKELY than a serious one.

Opposed to: base-rate neglect where you do worst-case scenario rule out

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27
Q

What is posterior probability error?

What is it the opposite of?

A

Physician estimates the likelihood of disease based on what has gone on before for the patient.
Ex. patient presents 5 times for ethanol intoxication. On the sixth time, the physician assumes it is the same thing.

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28
Q

What is premature closure?

A

When the diagnosis is accepted before it has been fully verified.

“when the diagnosis is made, the thinking stops”

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29
Q

What is the representativeness restraint cognitive bias?

A

physician looks for prototypical presentations of disease.

This can lead to atypical variants being missed

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30
Q

What is search satisfying?

What is often missed with this cognitive bias?

A

tendency to call off a search once something is found.

Misses:

  1. comorbidities
  2. co-ingestions
  3. multiple fractures
  4. multiple foreign bodies
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31
Q

What 3 cognitive biases are selection errors/biases?

[not considering the right diagnosis]

A
  1. premature closure
  2. diagnosis momentum
  3. search satisfying
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32
Q

What are the 4 major information errors/biases?

[consider correct diagnosis, but weigh incorrectly]

A
  1. availability/anchoring
  2. representativeness restraint
  3. general attribution errors
  4. epi/biostat errors
    - base rate neglect v. playing the odds
    - gamblers fallacy v. posterior probability error
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33
Q

What are the 2 keys to becoming an HRO [high reliability organization]?

A
  1. constantly reinventing

2. function as a learning organization

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34
Q

What is the PDCA cycle?

A

Plan
Do
Check
Act

35
Q

What quality improvement tool is used to identify possible causes of a problem in the context of team brainstorming?

A

Ishikawa/fishbone diagram

36
Q

What quality improvement tool is used when trying to solve problems enmeshed in complex work-flow environments like a busy ED?

A

process flow charts/mapping

37
Q

What quality improvement tool is used after a serious of bad outcomes has occurred [or a single disasterous outcome]? What are the 5 steps?

A

Root Cause Analysis

  1. problem definition
  2. understand the process [every problem is a process failure]
  3. identify all possible causes
  4. data collection
  5. data analysis
38
Q

In what stage of PDCA would it be appropriate to use a checklist and Pareto diagram?

A

Do

39
Q

What quality improvement tools would determine whether intervention was successful?

A

Run and/or Control Chart

40
Q

What is a type 1 error?

A

Falsely rejecting the null hypothesis

[finding an association when the variables are NOT associated]

41
Q

What is a type 2 error?

A

Falsely accepting a null hypothesis

[finding no association when in fact there is one]

42
Q

What is a-probability?

What value of a is most often chosen?

A

Alpha probability is the probability of making a type 1 sampling error [falsely rejecting a null hypothesis]

a is most often 0.05

43
Q

What is “certainty”?

The level of certainty most often chosen is what?

A

the probability that you will NOT make a type i error [falsely rejecting a null hypothesis]
Certainty is 1- alpha so the most often value is 0.95

44
Q

What is b-probability?

What is the value most often chosen?

A

It is the probability that you will make a type II sampling error [falsely accept the null]

B is chosen as 0.20

45
Q

What is “power” of a study?

A

The probability that you will NOT make a type II sampling error [you will not falsely accept the null]

Value of power is chosen to be 0.80

46
Q

What are the 5 steps for designing a study?

A
  1. define the purpose of the study
  2. formulate the “null hypothesis”
  3. choose a study design
    - experimental
    - observational
    - prospective v retrospective
    - historical perspective
  4. avoid sampling error and calculate sample size
  5. avoid bias
47
Q

What are the 3 general purposes of a study?>

A
  1. descriptive
  2. hypothesis-generating
  3. hypothesis testing
48
Q

What study design should be used for a descriptive study?

A

observational study like a survey using:

  • statistical [random]
  • or convenience sample
49
Q

What study design should be used for hypothesis-generating studies?

A

observational study like:

  • cohort
  • case control
50
Q

What study design should be used for hypothesis testing?

A 
1. experiment study
OR
2. observational study like:
-cohort
-case control

[but there must be extensive design features to avoid bias]

51
Q

What is a null hypothesis?

What is alternative hypothesis?

A

Null is a statement that is:
- non-directional and thus would be rejected if there was a change between control and experimental group.
- directional but worded as “no lower than” or “no greater than”
Alternative is if there treated group and control group are different

52
Q

If the null hypothesis is non-directional, the statistical analysis will employ a ___________ test of significance.
If the null hypothesis is directional, the statistical analysis will employ a _______ test.

A

Non-directional would use 2-tailed test

Directional would use 1-tailed test

53
Q

Which is more likely to yield a significant result: one tailed test or 2-tailed test?

A

One tailed

54
Q

What is the difference between an experimental study and an observational study?

A

Experiemental: predictor is under control by the investigators and is randomized and controlled

Observational: investigators observe natural occurrences but may select the events so to reduce bias

55
Q

Describe a simple experiment.

A

subjects are randomly assigned to treatment or control groups and followed to determine outcome.

Best design: double-blind

56
Q

Describe repeated measures experiment.
How does it differ from simple experiment?
What is the major benefit?

A

Subjects are assigned to treatment or control groups.

It differs from simple experiment because 2 or more measurements are recorded in all subjects in both groups
[one measure before intervention, 2nd after]

Benefit: each patient serves as his/her own control so this eliminates the effects of wide variation on outcome

57
Q

Describe repeated measure with crossover.

When is this useful?

A

A repeated measure experiment is completed and then the experiment is continued with the same subjects except the placebo and treatment groups are flipped after a sufficient time delay.

It is useful when there is extreme variation in the outcome event

58
Q

What are the 2 main types of observational study designs?

A
  1. Cohort- subjects are selected based on exposure to a risk factor/treatment and are followed to determine if they develop the disease
  2. Case-Control study - subjects that have the disease are studied to determine which ones were exposed to the risk factor/treatment
59
Q

Describe prospective and retrospective studies.

A

prospective and retrospective designate the time at which data was collected with respect to exposure and disease occuring.

Prospective - data on exposure/disease is measured as it occurs
Retrospective- data is collected long after they occurred

60
Q

What is a nested case-control study?

A

It is a prospective case-control study. This means the person has the disease and is currently having data collected to see what exposures/treatments they have

61
Q

What is a historical prospective study?

A

A retrospective cohort study

62
Q

What are the 4 main types of errors and bias in epidemiology?

A
  1. sampling error
  2. selection bias
  3. information bias
  4. confounding
63
Q

What is sampling error?
What usually causes it?
What are the 2 types?

A

It is when there is a distortion of the estimate of association resulting from chance variation in the selection of sample.

It occurs when the sample size is too small.
Type 1 - find an association when there is not
Type 2 - don’t find an association when there is one

64
Q

What is a, B, and power?

What are the usual numeric goals for these variables?

A

Alpha is the likelihood that a type 1 error will occur
a = 0.05

Beta is the likelihood that a type 2 error will occur
b= 0.2

Power is 1-B
p= 0.8

65
Q

There are complex calculations for a and B that involve the size of the sample to be drawn from the population of interest. In general, what is the effect of the sample size on alpha and beta?

A

As the population sample size gets larger, the likelihood of these errors decreases.

66
Q

What is the main benefit and main drawback of having a really large sample size?

A

Benefit: larger sample sizes have smaller a and B errors

Drawback: the study is more difficult to perform

67
Q

The parameter of power [1-B] is especially important in what type of study?

A

it is useful in studies to show equivalence [generic drug is as effective as brand name, etc]

68
Q

Once data has been gathered, if a difference is found, the probability that a type 1 error [alpha] occurred is estimated by what?
If no difference is found, what is stated instead?

A

Difference:
calculated alpha by using
P-value obtained from a test of statistical significance

No difference:
State the power of the test

69
Q

Describe examples of selection bias.

A
  1. picking populations using different methods
    - select patient exposed to a risk factor by picking hospital exposed
    - select patients not exposed by taking volunteers
  2. larger dropout rate/non-response rate in one group
  3. longer survivorship in one group
70
Q

What is information bias?

A

Distortion in the estimate of association due to measurement error or mis-classification of subjects

ex. invalid measurements, incorrect diagnostic criteria, systematic omission of medical records, different measurement techniques in exposed/unexposed

71
Q

What is confounding?

A

bias when the causal effect of a risk factor is inflated or deflated due to the presence of one or more extraneous variables that are co-linked with the risk factor and outcome variable.

ex. coffee–> heart disease OR coffee drinkers are more likely to be smokers –> heart disease OR anxious people are more likely to drink coffee or smoke –> heart disease

72
Q

How are observations quantified in observational studies?

What is used to draw infrences?

A

Quantified with:

  1. incidence
  2. prevalence

Inferences are drawn by identifying:

  1. Relative Risk
  2. Attributable risk
73
Q

How are observations quantified in experimental studies?

What is used to draw inferences?

A

Quantified with:

  1. control and experimental event rates
  2. absolute and relative risk ratios

Inferences drawn with:
NNT
NNH

74
Q

What is incidence?

What is the equation for incidence rate?

A

Number of new events in a defined population in a defined time.

Incidence Rate = [number of new events]/[number of people at risk]

ex. 650 out of 1.5 million developed aids in dallas in 1991 so the incidence rate is 650/1.5mill or 43 cases per 100,000

75
Q

What is prevalence?

What is the equation for prevalence rate?

A

Prevalence is the number of active cases in a defined population and defined time.

Prevalence rate = [total active cases]/[number of people at risk]

76
Q

What is the relationship between prevalence and incidence?

A

Prevalence is proportional to incidence x time duration

77
Q

What is relative risk?

A

Rate in the exposed/Rate in the unexposed

78
Q

What is attributable [absolute] risk?

A

Rate in the exposed minus rate in the unexposed

79
Q

If you are using a 2x2 chart, what is Re, Ru, RR, and AR?

A 
Re = a/[a+c]
Ru= b/[b+d] 
RR = Re/Ru
AR = Re - Ru
80
Q

Which is a more meaningful measure relative risk or attributable [absolute] risk?

A

attributable [although RR is easier to estimate when using more complex epidemiological tools]

81
Q

What is CER?

What is EER?

A

CER is the control events ratio.
EER is the experimental event ratio

CER = [number in control group with outcome]/[entire control group]

EER = [number in experimental group with outcome]/[entire experimental group]

82
Q

What is relative risk ratio?

What is the attributable risk ratio?

A

RRR = [CER-EER]/CER

ARR = CER-EER

83
Q

What is the calculation for NNT?

A

1/ARR

which is equivalent to 1/[CER-EER]

Clinical Reasoning (9 decks)

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