PPD - Clinical Decision Making, Developing Teaching Skills Flashcards
What is a doctor
one who has ultimate responsibility for difficult decision, using knowledge and judgement
Modern educational values (x3)
Knowledge, skills, feelings (NOT judgement)
Bernoulli expected utility theory - equation and issue
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
Authors involved in clinical decision making and their theories
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)
Define intuition
ability to understand something instantly without conscious reasoning
Advantages and disads of intuitive decision making
Ads
- Fast and frugal - using heuristics (cognitive shortcuts)
Disads
- Strong - cognitively predisposed to recognise
- Prone to biases
Types of heuristics
Heuristics is cognitive short cuts.
- Availability (Recent experience dominates evidence)
- Anchoring (Undue emphasis is given to an early salient feature in a consultation)
- Representativeness
4 types of bias in intuitive thinking
- Error of over-attachment
eg. confirmation bias - 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) - 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) - 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.’)
What is analytical decision making and what are ads and disads
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
How to reduce risks of intuition
NB. cant stop intuition - it is irresistible
- Decision environment and process
- Personal debiasing techniques (e.g. take a moment to think if you’ve missed anything)
- Structural debiasing (e.g. certain conditions can only be discharge by consultant etc.)
Explain how decision environment affects intuition
- Decision density (more decisions is more difficult) and contingency (one decision may rely on another decision)
- Physical environment (noisy)
- Process environment
Personal debiasing
Affective biasing
- Acknowledgment of bias
- Personal accountability (fatigue, hunger, relationship issues)
Cognitive debiasing - executive override
- slowing and stopping techniques
- cognitive forcing strategies
Structural debiasing
- training in DBT (dual process theory)
- structural forcing strategies
- checklists
- group decision strategies: MDTs, ward rounds
What is DPT
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
Issue with DPT
Sometimes intuitive thinking and analytical thinking may result in conflicting conclusions
3 teaching approaches
lecturer said we don’t specifically need to know these??
- cognitive (transmissive) eg lecture - constant feeding of information (fuel pump image)
- Nurturing approach (based on humanism) - if you create the right conditions someone will learn - seed to plant image
- Constructivism - teacher and learner working together (brick wall image)
Issues with cognitive/transmissive teaching approach
- teacher cant check students’ progress/understanding
- failure to ‘get’ a concept/idea compromises everything that follows
- metaphors and analogies are a powerful communication tool
4 steps in skills teaching (know these)
Paten model
- Trainer runs through without commentary
- Trainer talks through and trainer does
- Learner talks through and trainer does
- Learner talks through and learner does
Common pitfalls for skills teaching
- 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
Skills teaching: teaching and learning elements
- 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)
Benefits of small group teaching
Engaging and interacting are essential aspects of teaching.
Group communication should be facilitated by tutor NOT taught by tutor
Types of communication in small group learning
- 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 strategies
- 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
Types questions x4 (GP model)
- 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’
