SIM Man: Revision

Question 1

What is cognitive bias?

Answer 1

A type of error in thinking that occurs when people are processing and interpreting information.

They are often a result of our attempt to simplify information processing.

These biases can lead to poor decisions and bad judgements.

‘HEURISTICs’ or mental shortcuts can lead to errors.

These biases aren’t necessarily all bad: they can allow us to reach decisions quickly, which can be important in life threatening or dangerous situations

Question 2

What is availability bias?

Answer 2

The tendency to make a decision due to the ease of recalling a past similar case rather than on the basis of prevalence or probability.

I.e. You see something and remember a situation that was similar and just assume it’s the same thing

Question 3

How can we avoid availability bias?

Answer 3

Think about how PROBABLE a condition or event is really likely to be. Reconsider it in light of NEW data or an unexpected series of events that challenges your initial thinking e.g. Ask yourself… But what if they haven’t taken a medication causing the side effect I think it is- then what else could be causing this muscle pain?!

Do not just assume it’s the same as something you’ve seen before- every case is a new case with new causes!!

Question 4

What is anchoring bias??

Answer 4

A tendency to fixate on first impressions.
It’s when you use the first piece of information given to you to make your subsequent judgements. “As soon as I saw she had… I immediately thought she had.. So I let this sway my other thoughts”
Once the anchor is set, other judgements are made by adjusting away from the anchor.

Question 5

How can we avoid anchoring bias?

Answer 5

It’s difficult to avoid!

People tend to make an anchoring bias decision even when they are aware it exists

Question 6

What is premature closure bias?

Answer 6

Where you make a decision based on limited evidence without considering other possible explanations, or without actively searching for further information that may contradict your earlier thoughts.
Rushing to a decision, kind of lazy.. You should always make sure you have all the information you need before making a decision otherwise you might miss important things!!

Example: you assume that a patients worsening chest condition is due to a beta blocker that has been recently started, without considering that it could be due to worsening of their condition or maybe an infection- have you asked for their temperature and CRP level to RULE THIS OUT?!
Premature closure: closed the case and made a decision too early.

Question 7

How can we avoid premature closure bias effecting out decisions?

Answer 7

Come back and reconsider the case with a fresh mind or when less distracted.
Consider extremes or “red flags” eg. ‘What is the important condition that I do not want to miss here before jumping to a conclusion?’

Question 8

What is framing bias?

Answer 8

Being swayed by the way in which is problem is phrased may effect your decisions as for example one phrase may make something sound better than another:

Drug X saves 8 lives out of 10
Drug Y fails to save 2 lives out of 10
Most people would want drug X because it SOUNDS better!!

Question 9

How can we avoid framing bias?

Answer 9

By using clear language.

Include both the benefits and the risks in the information

Use absolute risk and relative risk for clarity:
Relative risk looks bigger compared to absolute risk

Question 10

What is representativeness bias?

Answer 10

Where we assume that something seems similar to other things in a category so itself must be a member of that category (we don’t consider prior probabilities)

E.g. Assuming that just because a school pupil represents Form 6B, that school pupil must belong to Form 6B (when they don’t necessarily!!)

Question 11

How can we avoid representativeness bias?

Answer 11

Consider base rate probabilities and be guided by these.

Don’t be persuaded about how much a case may resemble the group you are trying to put it into!!

Question 12

What is confirmation bias?

Answer 12

The tendency for people to favour the information that confirms their beliefs or hypotheses.
People tend to interpret ambiguous information to support their beliefs. We may look out for information that fits with our pre-existing expectations.
We may ignore data that is inconsistent with the diagnosis and suggests other diagnosis

E.g. You are checking a prescription for Humalog.
You pick up a product expecting to see Humalog (because it is where it’s normally is). You do not notice the product is actually Humulin because you expected it would be Humalog

Question 13

How can we avoid confirmation bias?

Answer 13

Take a step back and actively seek out information that may challenge your preconceptions.
Ask yourself questions that would disprove rather than support your hypothesis…
Remember you are wrong more often than you think!

Question 14

What are the six different types of cognitive bias?

Answer 14

Availability bias
Anchoring bias
Premature closure bias 
Framing bias
Representativeness bias
Confirmation bias

Question 15

What four factors can influence your decision making?

Answer 15

Evidence- behind the use of that medicine, background knowledge etc
Yourself- be aware of your behaviours, attitudes, emotions, values, beliefs
The patient / scenario- their preferences, experiences, the current situation
Environment- be aware of your decision making process

Question 16

What is analytical reasoning??

Answer 16

Where you base judgements solely on what is in front of you.

You gather and weigh up data against mental rules.

It assumes there are causal rules that link clinical features to diagnoses. With experience these rules become refined and attuned to reality: I.e drilled into your head.

Question 17

What is Non-analytical reasoning?

Answer 17

Pattern recognition- identifying patterns in cases.
It’s automatic- your brain automatically retrieves past experiences.
It’s rapid and unconscious- I.e. You probably don’t know you’re doing it.
You compare the current patient to past patients
Similar to availability biased!
May increase with experience: “I saw this case before a couple of years ago…”

Question 18

What does clinical reasoning involve: analytical or non analytical reasoning?

Answer 18

It involves a bit of both!

Analytical and non-analytical reasoning should integrate smoothly and unconsciously.

Question 19

Which can lead to more diagnostic error: an excessive reliance on analytical or non-analytical reasoning?

Answer 19

Non-analytical reasoning can lead to more chance of error when diagnosing as you think back to previous situations and are more likely to miss something vital.
We need to promote more analytical reasoning by instructing prescribers to list the evidence president to support their case!!

Question 20

Clinical reasoning and decision making involves a balance between analytical and non-analytical reasoning, trying not to allow too much non-analytical reasoning to take over.

Answer 20

The ideal situation: trust feelings of similarity (non-analytical) but avoid ‘jumping to conclusions’ by also using a diagnostic algorithm (analytical) e.g. Check patient notes, test results, past medical history, ask about symptoms… Follow a plan and fulfill each stage

Question 21

What are heuristics?

Answer 21

Short-cuts in clinical reasoning
These can sometimes be useful as they help us deal with lots of information quickly.
We commonly use these mental shortcuts when we are uncertain about something.
But heuristics can lead to evidence being BIASED

Question 22

Which should we use to guide our decisions: Relative risk or absolute risk? Why?

Answer 22

Absolute risk
It improves our understanding

Relative risk leads to people overestimating the actual risk.
E.g.
New antihypertensive can reduce the risk of stroke by 50% compared with current therapies (Relative Risk)

This is only an absolute risk reduction of 1.5% over 5 years

See how different they sound?

Question 23

What type of bias does relative risk and absolute risk fall under?

Answer 23

Framing biased

Making thinking sound better the way they are phrased

Question 24

What is absolute risk reduction (ARR)?

Answer 24

The difference between the risk if an event in a control group and the risk of an event in the treatment group

This gives a better understanding of how beneficial a treatment actually is than relative risk reduction

Question 25

How do we work out relative risk reduction (RRR?

Answer 25

Control group rate - experimental group rate

All divided by control group rate

Usually makes us overestimate things and see drugs to be more beneficial than they actually are: drug companies often use it to advertise their drugs!!
A type of framing biased

Question 26

One way we can minimise bias is by using CHECKLISTS. These can be generic or disease specific.

Answer 26

Generic: generate an initial hypotheses (what you think it may be) and differentiate (look for things that indicate it’s NOT this) using additional exams, history, and tests.
E.g. Patient feels dizzy. You think it may be postural hypotension. Take a pulse reading and look for it being normal which would say it’s probably not postural hypotension. Look in medical history to see if they are on medication OTHER than antihypertensives that could have a side effect of dizziness. Try and prove yourself wrong.

Disease specific: forces you to go through the different options: is there presence or absence of particular disease features

Question 27

Can you think of 5 reasons why records are always kept with regards to patient care?

Answer 27

To record patient details

To provide a full assessment of the patients needs an identify any factors that may have affected our patients progress

To provide evidence of the care required, the interventions taken by professional practitioners and the response the patient had to these

To provide a chronology of events: why did we take the actions we took?? Why did we make those decisions?

To use as a baseline record to refer back to, in order to determine whether improvement or deterioration has occurred: looking at the patient notes has their condition deteriorated since we made the last intervention, stayed the same, or improved?

Question 28

How should patient records be made?

Answer 28

Factual: e.g. “She has chest pain when lying on left side”
Put them in chronological order- arrange in order of time the patient said they occurred

Records should not include any abbreviations (unless they’re approved by the trust so understood by all), nor any jargon or meaningless phrases (use phrases that everyone can relate to and understand)

They should be written in terms the patient will be able to understand and where possible the HCP should include them when making the records.

Each record should be accurately dated, timed and signed with the writers name printed alongside the first entry. Time using the 24 hour clock!

Write the records in black ink/ biro!! Avoids people doing it in pencil etc

Question 29

In terms of legality, why is it so important to record everything we do in patient care?

Answer 29

In order to be able to present as evidence as to why decisions were made in patient care to the necessary regulatory body

If an allegation is made against the Trust or the HCP, they must have all the elements and standards in place to support their case

Managers are responsible to ensure that all clinical notes are maintained to a sufficient professional standard as well as those making the records in the first place

In law: if it hasn’t been written down… It hasn’t happened!

Question 30

In law: if it hasn’t been written down anywhere: it didn’t happen!!

Answer 30

You need to protect yourself and your patients by keeping accurate and safe records of actions taken and care given

Question 31

What’s the difference between explicit or implied consent?

Answer 31

Explicit: specific consent to carry out a specific action “yes I give give you consent to touch my chest”

Implied: not expressly given by a patient but inferred from their actions- may even be a patients silence or inaction. “I’m going to touch your chest if that’s okay” - “nods”

Generally there is NOT a legal requirement to obtain WRITTEN consent- although this may be advisable in some situations

Question 32

When must consent be gained?

Answer 32

Before any examination, treatment or care for competent adult patients.
So for example for taking someone’s blood pressure

Question 33

How do we make sure patients can give informed consent about something?

Answer 33

Patients need to have sufficient information before deciding whether to give consent: information on the benefits and risks of proposed treatments, alternative options.

If a patient is not given all the information they need to make an informed decision or in a form they can understand then their consent may not be seen as valid.

Question 34

Consent is a continuing process rather than a one-off decision. What does this mean?

Answer 34

It is important that the patient is given continuing opportunities to ask further questions and review they decision: I.e. Once they make their decision, they don’t have to 100% stick by it if something they find out at a later stage puts them off

Patients can change their mind and withdraw consent at any time as long as they have capacity to do so

Question 35

What does CAPACITY mean?

Answer 35

The ability to use and understand information to make a decision/ give consent on something

All adults are assumed to have capacity unless there is sufficient evidence to suggest otherwise

Question 36

Why may someone lack capacity?

Answer 36

If their mind or brain is disturbed e.g. Mental health, dementia, learning difficulties

This impairment means they’re not able to make a decision at the current time.
They may not be able to understand the information given or remember the information (e.g. In dementia). They may not be able to communicate their decision by talking

Question 37

If a patient expresses their wishes towards something I.e. Whether they agree to something being treated or not, but they later are deemed to lack consent, what should we do with regards to the treatment?

Answer 37

The previously expressed wishes should be respected even if the person can of give consent at a later stage. So if they once said it was okay to treat can look back at this rational decision they made.

Question 38

Some people may exhibit changes in capacity. What does this mean?

Answer 38

They may have capacity to make some decisions but not others.

Their capacity may come and go.

People can be considered capable of deciding some areas of their treatment but not others: e.g. A person with severe learning difficulties may be able to decide their day to day treatment but not long term treatment

People may have periods where they are capable and periods where they are incapable e.g. Patients with schizophrenia

Question 39

What is an “advance decision”?

Answer 39

If a person knows their capacity may change they can make an advance decision, stating any treatments they would like to refuse in case of future incapacity.

E.g. People say they would not want to be put on a life support machine if it came to it.

Question 40

Can you think of any examples of unacceptable patient boundaries?

Answer 40

You and your patient call eachother friends and interact outside of work.
Valuable gifts are exchanged
You discuss the patient during social interactions with your friends or family

Question 41

What is a dual relationship between a professional and a client??

Answer 41

When you have a therapeutic relationship with the patient but you also have some form of interaction with them outside of work e.g. You attend the same church. Your options could be: assign the client to another HCP or avoid the interaction by going to a different church service