Analytical versus non-analytical clinical reasoning

2. Analytical versus non-analytical clinical reasoning Alireza Monajemi, MD-PhD Philosophy of science department Institute for Humanities and Cultural Studies EBM- weekly conference

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5. Dual process theory Non-analytical=system 1 Analytical=system 2 consciousness Slow and sequential Abstract and hypothetical thinking High effort Linked to working memory • Unconscious, automatic • Pattern recognition • Rapid, computationally powerful, massively parallel • Pragmatic • Not linked to working memory EBM- weekly conference

6. The importance of clinical reasoning The maintenance of clinical teaching expertise requires, in part, an understanding of strategies expert clinicians use, often unconsciously, to reason through diagnostic case presentations. EBM- weekly conference

7. The psychological mechanisms underlying such reasoning tendencies are not always available to introspection EBM- weekly conference

8. instructional techniques for • Maximizing the probability that students will become successful medical problem solvers and on strategies for accurately diagnose • assessing whether or not students have in fact developed the required competencies EBM- weekly conference

9. Approach to clinical case A 56 year-old man consults you because of pain in his left leg began 2 days ago and has been getting progressively worse. He states his leg is tender below the knee and swollen around the ankle. History of recent surgery and immobilization is positive. He has never had similar problems. No dyspnea. His other leg is OK.

10. Analytical reasoning One need not look very far to recognize that medical educators have traditionally focused on what are known as ‘analytic’ models of clinical reasoning. EBM- weekly conference

11. Analytical reasoning careful analysis of the relation between signs and symptoms and diagnoses are the hallmark of clinical expertise EBM- weekly conference

12. Analytical reasoning Generation of a differential list of relevant diagnoses and application of an appropriate diagnostic algorithm then allows each diagnosis to be weighted in terms of its relative probability EBM- weekly conference

13. Analytical reasoning clinical teacher admonishes a student to ‘be objective’ and ‘carefully consider all the evidence available before generating diagnostic hypotheses’. EBM- weekly conference

14. Analytic process in clinical reasoning EBM- weekly conference

15. Analytical reasoning • these models assume that physicians are aware of the a priori probability with which a particular diagnosis may present and the conditional probability associating each piece of evidence (e.g. signs, symptoms and diagnostic tests) with the diagnosis EBM- weekly conference

16. Analytical reasoning • close to the evidence-based medicine movement • Bayes’theorem or regression analyses EBM- weekly conference

17. Non-analytical reasoning • Solving problems in the light of prior knowledge and belief EBM- weekly conference

18. Non-analytical reasoning • the evidence that clinicians use non-analytic processes in reaching diagnostic decisions is indisputable EBM- weekly conference

19. Non-Analytic process in clinical reasoning EBM- weekly conference

20. Non-analytical reasoning It has been argued that the ability to use non-analytic bases of clinical decision making increases with expertise EBM- weekly conference

21. as a result, the use of pattern recognition should not be advocated among medical students for fear of potentially grim consequences EBM- weekly conference

22. Non-analytical reasoning Non-analytic bases of judgment are not inferior to more analytic forms of reasoning EBM- weekly conference

23. clinical teachers should inform their students that similarity to past instances can serve as a useful guide. EBM- weekly conference

24. excessive reliance on non-analytic approaches to clinical reasoning can be a source of diagnostic error EBM- weekly conference

25. Where does this leave the clinical teacher? First, it must be recognized that these two forms of processing are not mutually exclusive. EBM- weekly conference

26. It is highly probable that both forms of processing contribute to the final decisions reached in all cases (for both novices and experts). EBM- weekly conference

27. A combined model of clinical reasoning EBM- weekly conference

28. A critical factor , however, was that the analytic processing should be carried out in close temporal relation to performing the actual task of diagnostic judgment. EBM- weekly conference

29. Non-analytic processing is expected to dominate during the initial phases of considering a new case • Analytic processing is expected to play a dominant role in hypothesis testing EBM- weekly conference

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31. These two reasoning are complementary contributors to the overall accuracy of the clinical reasoning process, each influencing the other EBM- weekly conference

32. combined instruction resulted in greater diagnostic accuracy than did purely analytic instruction EBM- weekly conference

33. failure to perform an analytic confirmation results in premature closure EBM- weekly conference

34. “good problem solvers” = “good coordinators” of analytic and non-analytic processing EBM- weekly conference

35. Dual process theory Non-analytical=system 1 Analytical=system 2 reflective consciousness Slow and sequential Abstract and hypothetical thinking Controlled and responsive to instruction and stated intentions High effort Linked to working memory • Unconscious, automatic • Rapid, computationally powerful, massively parallel • Pragmatic (contextualizing problems in the light of prior knowledge and belief) • Low effort • Not linked to working memory EBM- weekly conference

36. Dual process theory Two different kinds of cognitive processing affect inferences and judgments. EBM- weekly conference

37. Critical thinking in medicine is now called reflective practice in medicine

38. Reflective practice in medicine EBM- weekly conference

39. Reflective practice in medicine has a multidimensional structure, comparing five sets of behaviors and reasoning processes that require both cognitive and affective skills.

40. Theoretical model of reflective practice in medicine

41. How to provoke analytical reasoning (1) read the case again, (2) write down the hypothesis previously indicated again, (3) list findings that support this hypothesis, (4)list t findings that oppose it, and (5) list findings that would be expected if the hypotheses at-hand 'would be true but that were not encountered in the particular case (6) to list alternative hypotheses if the first one they considered would prove to be incorrect. EBM- weekly conference

42. How to provoke analytical reasoning For each on e of these they were then asked to follow the same procedures: (7) listing findings consistent with the hypothesis, (8) those that contradict it, and (9) those that were expected but not present in the case. Based on this analysis, (10) to indicate their conclusions by ranking diagnostic hypotheses in order of likelihood (11) presenting a final diagnosis. EBM- weekly conference

43. Deliberate induction • A tendency to search alternative diagnoses in response to difficult or unexpected problems.

44. Deliberate induction • Feelings of discouragement to continue exploring the problem when initial hypothesis refuted by findings of investigation . • Viewing exploration of signs and symptoms that are not compatible with the conjectures made about a patient's problem as a worthwhile device for reaching a diagnosis. • Experiencing feelings of disappointment when first diagnosis for a patient's problem not confirmed by the findings of investigation . • Considering that social and psychological factors, although seldom cause of disease, Deliberate contribute to its exacerbation. • Seeing reflection about a patient 's problem as goo d only for those physicians who can afford the time to do it. • Percept ion of certainty about evidence of effectiveness of prescribed measures due to recent literature review. • Undertaking initiatives to modifying practice's procedures and/or routines in order to allow solutions to patient's problems, when their management required those adjustments. • Discussing/ looking for consultation with colleagues led by difficulties perceived in managing a case.

45. Deliberate deduction • Explore signs & symptoms that might present if any one of these alternate hypotheses become true. = Backward reasoning

46. Deliberate deduction • Acknowledgment that had encountered patients to whom the clinical appraisal didn't lead to diagnostic, who required a differential diagnosis including the possibility of a severe problem • Designing a systematic plan for exploring all the hypotheses formulated for the patient's problem, when a severe, difficult problem was considered. • Going straightforward the most complex exam, based on the idea that it could quickly bring a conclusion about the severe disease whose possibility had been considered • Looking for additional information by reviewing literature when dealing with cases with unexpected poor treatment outcomes. • Discussing/looking for consultation with colleagues led by difficulties perceive in managing a case

47. Test & Synthesize • A willingness to test these hypotheses and synthesize new understandings about the problem.

48. Test & Synthesize • After having seen a patient he/she said to him/herself: "What should I do differently next time " • When a very complex case he/she has been dealing with has reached its completion, he/she usually feels relieved • He/she has faced uncomfortable or troublesome situations generated by his/her • He/she adjusted treatment in the light of knowledge about feasibility of possible measures he/she had acquired while dealing with previous similar patients. • He/she used his/her experience with similar patient s in the past to assess feasibility of the measures he/she was considering for the treatment.

49. Openness to reflection • Engage in reflective reasoning in response to changing problems • Tolerate uncertainty and ambiguity

50. Openness to reflection • Experiencing feelings of distress when encountering difficult patients. • Waiting and observing evolution of a patient to whom clinical assessment did not lead to a diagnosis, whenever possible. • Mentally rehearsing, during the evenings. some of the cases he/she had see n during the day. • Having patients whose problems he/ she had difficulties in understanding or managing g • crossing his/her mind at a later stage. • Considering own practice too busy. leaving only limited time to reflect on cases he/she is dealing with.