PPD - Clinical Decision Making, Developing Teaching Skills

Question 1

What is a doctor

Answer 1

one who has ultimate responsibility for difficult decision, using knowledge and judgement

Question 2

Modern educational values (x3)

Answer 2

Knowledge, skills, feelings (NOT judgement)

Question 3

Bernoulli expected utility theory - equation and issue

Answer 3

EU = likelihood x value of the event happening.

In theory, should be able to anticipate the outcome of any set of circumstances however humans are not good at estimating likelihoods and value

Question 4

Authors involved in clinical decision making and their theories

Answer 4

Kahneman and Tversky

Novices decide analytically

Experts decide using intuition (hinges of pattern recognition)

Problems arise when people use intuition before they are ready (think they can recognise the
pattern but they can’t)

Question 5

Define intuition

Answer 5

ability to understand something instantly without conscious reasoning

Question 6

Advantages and disads of intuitive decision making

Answer 6

Ads
- Fast and frugal - using heuristics (cognitive shortcuts)

Disads

• Strong - cognitively predisposed to recognise
• Prone to biases

Question 7

Types of heuristics

Answer 7

Heuristics is cognitive short cuts.

• Availability (Recent experience dominates evidence)
• Anchoring (Undue emphasis is given to an early salient feature in a consultation)
• Representativeness

Question 8

4 types of bias in intuitive thinking

Answer 8

1. Error of over-attachment
   eg. confirmation bias
2. Error due to failure to consider alternative
   eg. search satisfaction (Having found one diagnosis, other co-existing conditions are not detected; eg missing the 2nd fracture after finding 1st fracture in trauma patient)
3. Error due to inheriting thinking
   eg. diagnosis momentum (paramedic hands over patient with working diagnosis and dr takes this working diagnosis to be true diagnosis without reconsidering)
4. Errors in prevalence perception or estimation
   eg availability bias (Recent experience dominates evidence)
   eg. Gambler’s fallacy (The tendency to think that a run of diagnoses means the sequence cannot continue, rather than taking each case on its merits. eg. ’I’ve seen 3 people with acute coronary syndrome recently; this can’t be a fourth.’)

Question 9

What is analytical decision making and what are ads and disads

Answer 9

We may not be good at estimating odds/values but we are good at measuring and calculating them (basis for EBM).

Ads

• accurate
• reliable

Disads

• Slow - keeps other patients waiting
• Resource-intensive - costs money
• Cognitively damaging - exhausting

Question 10

How to reduce risks of intuition

Answer 10

NB. cant stop intuition - it is irresistible

1. Decision environment and process
2. Personal debiasing techniques (e.g. take a moment to think if you’ve missed anything)
3. Structural debiasing (e.g. certain conditions can only be discharge by consultant etc.)

Question 11

Explain how decision environment affects intuition

Answer 11

1. Decision density (more decisions is more difficult) and contingency (one decision may rely on another decision)
2. Physical environment (noisy)
3. Process environment

Question 12

Personal debiasing

Answer 12

Affective biasing

• Acknowledgment of bias
• Personal accountability (fatigue, hunger, relationship issues)

Cognitive debiasing - executive override

• slowing and stopping techniques
• cognitive forcing strategies

Question 13

Structural debiasing

Answer 13

• training in DBT (dual process theory)
• structural forcing strategies
• checklists
• group decision strategies: MDTs, ward rounds

Question 14

What is DPT

Answer 14

Dual process theory

Intuitive thinking with its irresistible combination of heuristics and biases together with

analytical thinking, using EBM

Sometimes decisions are a combination of intuitive and analytical thinking, not either or

Question 15

Issue with DPT

Answer 15

Sometimes intuitive thinking and analytical thinking may result in conflicting conclusions

Question 16

3 teaching approaches

lecturer said we don’t specifically need to know these??

Answer 16

1. cognitive (transmissive) eg lecture - constant feeding of information (fuel pump image)
2. Nurturing approach (based on humanism) - if you create the right conditions someone will learn - seed to plant image
3. Constructivism - teacher and learner working together (brick wall image)

Question 17

Issues with cognitive/transmissive teaching approach

Answer 17

• teacher cant check students’ progress/understanding
• failure to ‘get’ a concept/idea compromises everything that follows
• metaphors and analogies are a powerful communication tool

Question 18

4 steps in skills teaching (know these)

Answer 18

Paten model

1. Trainer runs through without commentary
2. Trainer talks through and trainer does
3. Learner talks through and trainer does
4. Learner talks through and learner does

Question 19

Common pitfalls for skills teaching

Answer 19

• lack of clarity/thoroughness/ accuracy of description
• accuracy and consistency of demonstration
• failure to use all senses
• talking too much
• insufficient time for student
• no repetition
• failure to check understanding
• giving insufficient feedback

Question 20

Skills teaching: teaching and learning elements

Answer 20

• explanation (before/ during/ after)
• demonstration (sight/ tough/ other senses)
• steps and sequence (all or part of procedure, how it is put together)
• rehearsal (silent/ student narrative/ teacher narrative)
• repetitions (how many opportunities)
• evaluate and feedback (self/ patient/ teacher/ peer)

Question 21

Benefits of small group teaching

Answer 21

Engaging and interacting are essential aspects of teaching.

Group communication should be facilitated by tutor NOT taught by tutor

Question 22

Types of communication in small group learning

Answer 22

• rounds (go around and everyone speak)
• snowballing (start individually, then share with partner, then share with group)
• circular interviewing (sit in semicircle)
• line-ups (2 sides debate the issue? - good for ethical issues)
• buzz groups
• brainstorming

Question 23

Question strategies

Answer 23

• evidence: how do you know that? what evidence is there to support that?
• clarification: can you put that another way? give example?
• explanation: why might that be the case?
• linking and extending: Is there any connection between what you have just said and what Y said earlier? How does this idea support/challenge what we explored earlier in the session
• hypothetical: what might happen if?
• cause and effect: What is /isn’t drug X suitable in this condition? What would happen if we increased/decreased X?
• summary and synthesis

Question 24

Types questions x4 (GP model)

Answer 24

• didactic: telling ‘what you need to know here is’
• socratic: asking ‘what does that tell you about’
• heuristic: discovering ‘how might you find that out’
• counselling: feeling ‘how are you feeling about’