Medical Decision Making

Question 1

Diagnosis is missed or delayed in how many % of acute hospital admissions?

Answer 1

5-14%

Question 2

How many % of patients don’t receive evidence-based care?

Answer 2

Up to 45%

Question 3

How many investigations and drugs administered are potentially unnecessary?

Answer 3

Between 20-30%

Question 4

Almost half of errors involved reasoning or decision quality - what does this include?

Answer 4

Failure to elicit, synthesise, decide or act on clinical information

Question 5

What is the trouble with things going wrong?

Answer 5

The mistake is not always admitted to

Question 6

Why might mistakes not be reported? (5)

Answer 6

Staff didn’t know what to report or why
Patient was ‘unharmed’
Staff felt too busy to report
Lack of feedback when errors were reported
Fear of disciplinary action or litigation

Question 7

What is the person approach (explanatory model of human error)?

Answer 7

Healthcare professional is responsible. These are known as active errors, e.g. forgetfulness, negligence, poor motivation, carelessness, inattention

Question 8

What are the weaknesses of the person approach? (3)

Answer 8

Prevents analysis of what went wrong (no opportunity to change/improve)
Failure to recognise patterns of mistakes
Suggests mistakes are only made by bad doctors

Question 9

What is the systems approach (explanatory model of human error)?

Answer 9

This assumes that mistakes are inevitable because humans are fallible. Errors are consequences of unworkable procedures, inadequate equipment, fatigue, understaffing etc, rather than causes. This suggests the best way to prevent errors is to create a system which defends against human error.

Question 10

Explain the model of inductive clinical reasoning.

Answer 10

Initial collection of information from history/exam -> a series of logical problem solving steps -> diagnosis

Question 11

Explain the hypothetico-deductive model.

Answer 11

Collection of info from history/exam -> generate hypothesis -> analyse info to confirm/refute hypothesis -> diagnosis

Question 12

What is pattern recognition? What are the benefits?

Answer 12

It is a quick, often intuitive process based on experience of lots and lots of cases. This means that atypical presentations can still be spotted and that the experienced doctor will know what additional information is needed to complete the clinical picture.

Question 13

What are heuristics?

Answer 13

Cognitive shortcuts /decisional shortcuts e.g. rule of thumb, educated guess, common sense

Question 14

What are cognitive biases?

Answer 14

Systematic and predictable errors in judgement, resulting from reliance on heuristics. They are cognitive dispositions to respond in various ways in certain situations (over 30 have been identified).

Question 15

Give some examples of cognitive biases. (6)

Answer 15

Availability 
Representativeness
Anchoring
Diagnosis Momentum 
Fundamental Attribution Error
Commissioning bias

Question 16

What is meant by availability (cognitive bias)?

Answer 16

Things seem more likely if they readily come to mind, so a disease seen recently will seem more likely or over-diagnosing rare conditions because they are more memorable.

Question 17

What is meant by representativeness (cognitive bias)?

Answer 17

Diagnosis seems more likely based on how similar the characteristics are to typical cases. This only looks for prototypical manifestations of disease.

Question 18

What is meant by anchoring (cognitive bias)?

Answer 18

Perceived probability of event or diagnosis based on one trait or piece of information (e.g making a diagnosis based on a first impression).

Question 19

What is meant by diagnosis momentum (cognitive bias)?

Answer 19

Labels become attached to patients and they get more and more attached to the person, because the staff and family use the diagnosis, so it is hard to go back and change it so all other possibilites are excluded.

Question 20

What is meant by fundamental attribution error (cognitive bias)?

Answer 20

The tendency to blame people for their illness rather than the circumstances. This occurs particularly for psychiatric patients, minorities, those with substance abuse issues and other marginalised groups.

Question 21

What is meant by commission bias (cognitive bias)?

Answer 21

The tendency to action rather than inaction, such as prescribing tests or medication which are not necessary. It’s more common in over-confident doctors, but it’s also a function of what patients expect of medical encounters.

Question 22

How can we avoid cognitive bias? (9)

Answer 22

Develop insight/awareness
Consider alternatives
Metacognition (reflection)
Decrease reliance on memory
Specific training
Simulation
Make the task easier
Minimise time pressures
Establish accountability and possibility of feedback

Question 23

How does responsibility differ between informed and shared decision making?

Answer 23

Informed - responsibility lies with patient

Shared - responsibility is shared between patient and doctor

Question 24

Explain informed decision making.

Answer 24

The doctor gives the patient all the factual/medical information they need about treatments and the patient decides what treatment/management to have.

Question 25

Explain shared decision making.

Answer 25

The doctor and the patient are both involved. They discuss possible treatment/management options and the doctor gives their expert opinion/recommendation, and they both decide on the treatment/management together.

Question 26

Explain a doctor-centred consultation.

Answer 26

The doctor talks and the patient listens. The doctor makes decisions and tells the patient what to do.

Question 27

Explain a patient-centred consultation.

Answer 27

The patient expresses their own agenda. The doctor uses active listening to understand the patient’s point-of-view. They agree on diagnosis and management together.

Question 28

What are the benefits of patient-centred consultations? (3)

Answer 28

• Improve adherence
• Patient feels they have been heard (improves satisfaction)
• More likely to be able to prescribe a regime that the patient understands/can follow

Question 29

What are the issues with patient-centred consultations? (2)

Answer 29

• Might take some getting used to (especially for less experienced doctors)
• Feel less controlled, might go on too long