03/30/22
04/19/23
Analytical versus non-analytical clinical reasoning
Alireza Monajemi, MD-PhDPhilosophy of science department
Institute for Humanities and Cultural Studies
Wednesday, April 19, 2023 EBM- weekly conference
Wednesday, April 19, 2023 EBM- weekly conference
Wednesday, April 19, 2023 EBM- weekly conference
Dual process theory
Non-analytical=system 1• Unconscious, automatic• Pattern recognition• Rapid, computationally
powerful, massively parallel• Pragmatic • Not linked to working
memory
Analytical=system 2• consciousness• Slow and sequential• Abstract and hypothetical
thinking• High effort• Linked to working memory
Wednesday, April 19, 2023 EBM- weekly conference
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.
Wednesday, April 19, 2023 EBM- weekly conference
The psychological mechanisms underlying such reasoning tendencies are not always
available to introspection
Wednesday, April 19, 2023 EBM- weekly conference
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
Wednesday, April 19, 2023 EBM- weekly conference
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.
Approach to clinical case
04/19/23
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.
Wednesday, April 19, 2023 EBM- weekly conference
Analytical reasoning
careful analysis of the relation between signs and symptoms
and diagnoses are the hallmark of clinical expertise
Wednesday, April 19, 2023 EBM- weekly conference
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
Wednesday, April 19, 2023 EBM- weekly conference
Analytical reasoning
clinical teacher admonishes a student to ‘be objective’ and
‘carefully consider all the evidence available before
generating diagnostic hypotheses’.
Wednesday, April 19, 2023 EBM- weekly conference
Analytic process in clinical reasoning
Wednesday, April 19, 2023 EBM- weekly conference
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
Wednesday, April 19, 2023 EBM- weekly conference
Analytical reasoning
• close to the evidence-based medicine movement
• Bayes’theorem or regression analyses
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Non-analytical reasoning
• Solving problems in the light of prior knowledge and belief
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Non-analytical reasoning
• the evidence that clinicians use non-analytic processes in reaching diagnostic decisions is indisputable
Wednesday, April 19, 2023 EBM- weekly conference
Non-Analytic process in clinical reasoning
Wednesday, April 19, 2023 EBM- weekly conference
Non-analytical reasoning
It has been argued that the ability to use non-analytic bases of clinical decision
making increases with expertise
Wednesday, April 19, 2023 EBM- weekly conference
as a result, the use of pattern recognition
should not be advocated among medical students
for fear ofpotentially grim consequences
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Non-analytical reasoning
Non-analytic bases of judgment are not inferior to more analytic forms of
reasoning
Wednesday, April 19, 2023 EBM- weekly conference
clinical teachers should inform their students that similarity to past instances can serve as a useful guide.
Wednesday, April 19, 2023 EBM- weekly conference
excessive reliance on non-analytic approaches to clinical reasoning can be a source of
diagnostic error
Wednesday, April 19, 2023 EBM- weekly conference
• Where does this leave the clinical teacher? First, it must be recognized that these two forms of processing are not mutually exclusive.
Wednesday, April 19, 2023 EBM- weekly conference
• It is highly probable that both forms of processing contribute to the final decisions reached in all cases (for both novices and experts).
Wednesday, April 19, 2023 EBM- weekly conference
A combined model of clinical reasoning
Wednesday, April 19, 2023 EBM- weekly conference
A critical factor, however,
was that the analyticprocessing should be carried out in close
temporal relation to performing the actual task of diagnostic
judgment.
Wednesday, April 19, 2023 EBM- weekly conference
• 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
Wednesday, April 19, 2023 EBM- weekly conference
Wednesday, April 19, 2023 EBM- weekly conference
These two reasoning are complementary contributors to
the overall accuracy of the clinical reasoning process,
each influencing the other
Wednesday, April 19, 2023 EBM- weekly conference
combined instruction resulted in greater
diagnostic accuracy than did purely analytic
instructionWednesday, April 19, 2023 EBM- weekly conference
failure to perform an analytic confirmation
results in premature closure
Wednesday, April 19, 2023 EBM- weekly conference
“good problem solvers”=
“good coordinators” of analytic and non-analytic
processing
Wednesday, April 19, 2023 EBM- weekly conference
Dual process theory
Non-analytical=system 1• 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
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
Wednesday, April 19, 2023 EBM- weekly conference
Dual process theory
Two different kinds of cognitive processing
affect inferences and judgments.
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Critical thinking in medicine is now called
reflective practice in medicine
Reflective practice in medicine
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Reflective practice in medicine has a multidimensional structure, comparing five sets of behaviors and reasoning processes that require both cognitive and affective skills.
Theoretical model of reflective practice in medicine
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.
Wednesday, April 19, 2023 EBM- weekly conference
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.
Wednesday, April 19, 2023 EBM- weekly conference
• A tendency to search alternative diagnoses in response to difficult or unexpected problems.
Deliberate induction
• Feelings of discouragement to continue exploring the problem when initial hypothesisrefuted by findings of investigation .• Viewing exploration of signs and symptoms that are not compatible with the conjecturesmade 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 torecent 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.
Deliberate induction
• Explore signs & symptoms that might present if any one of these alternate hypotheses become true. = Backward reasoning
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
Deliberate deduction
• A willingness to test these hypotheses and synthesize new understandings about the problem.
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.
Test & Synthesize
• Engage in reflective reasoning in response to changing problems
• Tolerate uncertainty and ambiguity
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.
Openness to reflection
• Capability to reflect about one’s own thinking processes
• Meta-cognition
Meta-reasoning
• Questioning reasons underlying own decisions in order to check how far they were patient-centered.
• Realizing that own assumptions with regards to a patient problem could have distorted or restricted initial exploration of the problem.
• Viewing him/herself as a quite successful physician.• Experiencing cases in which he/she considered further
exploring the problem for defining a diagnosis was not justifiable.
• Attempting to forget very difficult cases after their completion.
• Reviewing specialist's approaches in referred case s in order to verify what he/herself could have done in a better way.
Meta-reasoning
Wednesday, April 19, 2023 EBM- weekly conference
Metacognition
Openness
Induction Deduction Test
Hypothesis formation(DDx)
Backward reasoning
Hypothesis evaluation
Reflective practice &
medical errors
Wednesday, April 19, 2023 EBM- weekly conference
Availability bias
تمایل به تشخیصی که در به علت دیدن موارئ مشابه در زمان جدید زود به ذهن خطور
ساله ای با درد ساق 40می کند. پزشکی خانم 1 تشخیص پای چپ را می بیند که نهایتا
میوسارکوما داده می شود. او پس از این هر بیماری با درد ساق پا را تشخیص میوسارکوم
می دهد.
Wednesday, April 19, 2023 EBM- weekly conference
Representativeness bias
تمایل پزشکان به اینکه تابلوی بالینی پروتوتیپیک را جستجو کنند بودن توجه به اینکه به این نکته توجه کند
که هر گردی، گردو نیست. به عبارت دیگر اگر به تابلوی نادر یک بیماری روبرو شوند چون دنبال پرزنتاسیون شایع و پروتوتیپیک
1 پزشکی در می گردند، آن را تشخیص نمی دهند.مثًالمرد میانسالی که با درد شدید سردل مراجعه کرده
است به انفارکتوس میوکارد شک نمی کند و با تشخیص اولسر پپتیک رانیتیدین وریدی تجویز می کند.
Wednesday, April 19, 2023 EBM- weekly conference
Overconfidence bias
یک تمایل عمومی است به اینکه بیشتر از آنچه عمل می کنیم می دانیم پس به همین دلیل بر
اسلس اطًالعات اندک، یا شمL یا شهود availability و Anchoringتصمیمی می گیریم.
Lهر دو بسیار با این خطا مربوط هستند. شممن می گوید این بیماری تشخیص اش این
است.
Wednesday, April 19, 2023 EBM- weekly conference
Anchoring bias
، بر first impression تمایل به فیکس کردن 1 اساس عًالئم و نشانه های بیمار دارند. مثًال
ساله که با کمردرد مراجعه کرده 70خانم دارد compression fractureاست و در گرافی
را با آنمی نرموسیتیک تشخیص میلودیسپًالستیک سندرم داده اند. بدون توجه به
تشخیص های افتراقی مثل میلوم مولتیپل که تشخیص اصلی این بیمار است.
Wednesday, April 19, 2023 EBM- weekly conference
Premature closure
پذیرفتن یک تشخیص بدون آنکه به طور کامل تائید شود در پرتو در نظر گرفتن تشخیص های افتراقی.
1 مرد ساله سیگاری قهLار و دیابتی که با 55مثًالاستفراغ مقاوم به درمان مراجعه کرده است و
پزشک با تشخیص گاستروپارزی دیابتی برای بیماری عکس ایستادۀ\ شکم درخواست می کند که حبابهای
هوا دیده می شود. او بودن در نظر گرفتن سایر علل ادو پاپی دوطرفه و آتاکسی مرکزی بیمار را
نادیده می گیرد. در سی تی اسکن صورت گرفته در فوسای خلفی ضایعه دیده می شود.
Wednesday, April 19, 2023 EBM- weekly conference
Confirmation bias
تمایل به جستجوی عًالئم و نشانه های تائید کنندۀ\ تشخیص و بی توجهی به سایر تشخیص ها.
Wednesday, April 19, 2023 EBM- weekly conference
Experimental research in reflective practice
Mamede, Schmidt, & Penaforte studt
• Reflective practices did not make a DIFFERENCE ON ACCURACY OF DOAGNOSIS IN simple cases.
• Reflective practices had a positive effect when diagnosing complex cases.
• We need more research to explore the nature of reflective practice in medicine.
• Doctors differs in the extent to which they engage in reflective practices when faced with complex clinical problems, ranging form very reflective to virtually non-reflective doctors, and these differences are measurable.
• The non-analytical, pattern-based clinical reasoning characteristic of expert doctors, although effective to solve routine cases, may lead to higher of diagnostic errors in novel complex situations.
• Reflective, analytical reasoning leads to higher accuracy of diagnoses in difficult, ambiguous, non-routine clinical problems, and enhancing reflective practice can be assumed as a strategy to minimize preventable medical errors.
• The ideal clinical problem solving approach entails combination of non-analytical and analytical reasoning.
• The continuous growth of scientific medical knowledge base, which nurtured the promise of a systematic, objective, evidence-based clinical practice, indeed has not reduced uncertainty, ambiguity and complexity of medical judgment.
• Meta-cognition as a way to teach clinical reasoning
• Deliberate practice should be continued during practice that is changed the paradigm of continuing education in medicine
• The way to reduce medical errors
Effects of RP
Wednesday, April 19, 2023 EBM- weekly conference