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Shared Decision-making 33
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Box 5.7 An example of a Patient Decision Aid (PDA)
Reproduced with permission from the British Menopause Society:
https://thebms.org.uk/publications/tools-for-clinicians (accessed July
2022).
Box 5.8 Mental checklist for use when considering the use of
decision aids
• Is there a decision tool that is helpful here?
• Have I checked that this is the correct tool to use with my
patient?
• Have I gathered all the information that I need from the patient?
• What is this individual patient’s context?
• What are this individual patient’s beliefs, values, and preferences?
• Can I explain this clearly to this individual patient, mindful of their
health literacy?
This emphasises the importance of directly consulting with patients
in the development of clinical reasoning, and some of those patient
encounters at an appropriate stage in learner development should
be unfiltered (e.g., in primary care or hospital assessment areas) to
maximise the learning potential of the encounter.
Box 5.8 shows a mental checklist for clinicians to use when
considering the use of decision aids for a specific consultation
with an individual patient.
Summary
Clinical decision-making can be supported by using a variety of
clinical guidelines, scores, and decision aids. These can help with
diagnostic and management decisions. However, the clinician must
ensure that the correct decision aid is used and it must be interpreted
within the context of a comprehensive clinical assessment, in which
good communication skills are crucial to undertaking a purposeful
history and physical examination. After a diagnosis is made, clinical
decision-making continues and should be shared between the clinician and patient whenever possible. During shared decision-making,
evidence-based medicine requires the clinician’s expertise to apply
scientific knowledge appropriately to the patient’s unique circumstances, and communicate in a way that is easily understood, being
mindful of each individual patient’s health literacy.
Acknowledgement
A proportion of this chapter is based on the original chapter written
for the first edition of the ABC of Clinical Reasoning. The authors
therefore wish to acknowledge the contribution of Professor Maggie
Bartlett (Professor Emeritus, Dundee University) to this chapter
through her co-authorship of the original chapter.
References
1. Shekelle PG, Woolf SH, Eccles M and Grimshaw J. (1999). Developing
guidelines. BMJ; 318: 593–596 (part of a four article series on the
development and use of clinical guidelines).
2. Wells PS, Anderson DR, Bormanis J et al. (1997). Value of assessment of
pretest probability of deep-vein thrombosis in clinical management. Lancet;
350(9094): 1795–1798.
3. The Rome Foundation. Rome IV Criteria. https://theromefoundation.org/
rome-iv/rome-iv-criteria. (Accessed July, 2022).
Lim WS, van der Eerden MM, Laing R et al. (2003). Defining community
4.
acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax; 58: 377–382.
5. Mayfield D, McCleod G and Hall P. (1974). The CAGE questionnaire: validation of a new alcoholism screening questionnaire. American Journal of
Psychiatry; 131: 1121–1123.
6. Sackett DL, Strauss SE and Richardson WS. Evidence-based medicine: how
to practice and teach EBM. London: Churchill-Livingstone, 2000.
7. Cobb P. Situated cognition: contemporary developments. In: Smelser NJ
and Baltes PB (Eds). International encyclopedia of the social & behavioral
sciences. Pergamon, 2001. pp 14121–14126.
8. Durning SJ, Artino AR Jr, Pangaro LN, van der Vleuten C and Schuwirth L.
(2010). Perspective: redefining context in the clinical encounter: implications for research and training in medical education. Academic Medicine;
85(5): 894–901.
9. Brown JS, Collins A and Duguid P. (1989). Situated cognition and the
culture of learning. Educational Researcher; 18(1): 32–42.
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CHAPTER 6
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Models of Clinical Reasoning
Nicola Cooper
OVERVIEW
• Models of clinical reasoning can be useful for clinicians, teachers,
and learners
Clinical reasoning can be viewed from different perspectives
•
• Critical thinking is not the same as clinical reasoning
• A dual process model is a widely accepted framework with which
to understand diagnostic reasoning and diagnostic error
• There is good evidence that rational decision-making often
requires a third process – termed reflective processing or
metacognition
• Expertise in clinical reasoning requires knowledge and experience,
but also motivation, effort, and metacognitive skills
Introduction
Models of clinical reasoning can be useful to help us understand
the processes underpinning our decision-making, as clinicians,
teachers, and learners. The problem is that clinical reasoning
research has its origins in the medical education, cognitive psychology, diagnostic error, and health systems literature. This fragmented literature makes it difficult for clinicians and educators to
access and adopt meaningfully into their practice. This chapter
therefore aims to summarise some of the literature related to
models of clinical reasoning.
Different Perspectives
Clinical reasoning can be viewed from different perspectives (see
Figure 6.1). One perspective is that clinical reasoning is to do with
knowledge, how knowledge is organised in long-term memory as
mental representations, and the cognitive processes responsible
for storing, transforming, and retrieving these. It is also about
how clinicians use analytic and non-analytic strategies interchangeably when facing a diagnostic problem [1]. This view of
clinical reasoning is informed by decades of research in the
cognitive sciences and by dual process theorists.
Another perspective is that clinical reasoning is something that
is ‘situated’ in the environment. Here, clinical reasoning is interdependent with various external factors such as the patient,
information technology (IT) systems, physical space, time constraints, and so on. This view of clinical reasoning is informed by
the situativity theories [2]. Accordingly, knowledge is not
something that exists solely inside a person’s organised cognitive
structures, but is entangled in the activity of providing care for the
patient [1].
Yet another perspective is that good clinicians need to be able
to go beyond the ‘content’ and make sense of the patient’s illness
(and their own response to it), to understand the practice of medicine in its wider socio-cultural context, and to ask: ‘What is going
on with this particular patient?’ This involves much more than
the application of knowledge or evidence-based guidelines. It
involves the ability to tolerate uncertainty and craft a deliberate
course of action appropriate for the circumstances – what we
might call wisdom [1]. This view of clinical reasoning is informed
by sociology, anthropology, and the humanities, including narrative medicine (see further resources).
All these perspectives are valid and valuable. As we stated in
Chapter 1, these perspectives are not mutually exclusive. However,
the focus for teachers and learners is very much on knowledge
and knowledge organisation, at least to begin with. As learners
progress, they can begin to understand clinical reasoning as
something that is situated in the environment where they can
make use of all the affordances available to them. Hopefully, with
time, they will learn to navigate beyond the content to become
wise clinicians.
Critical Thinking Vs Clinical Reasoning
Before we discuss a widely accepted model of clinical reasoning, it
is important to correct a common misunderstanding. ‘Critical
thinking’ is a term sometimes used interchangeably with clinical
reasoning, but they are not the same thing. Critical thinking is an
important component of reasoning in general. A definition of
critical thinking can be found in Box 6.1. But clinical reasoning
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
36 ABC of Clinical Reasoning
recognised
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It’s like a
huge fan …
It’s like a
snake!
Figure 6.1 Clinical reasoning and different perspectives. A group of blind
men heard that a strange animal had been brought to town so they went to
investigate. They gathered round and felt the animal carefully, each person
stating what they thought it was like. The parable of blind men and an
elephant is found in Buddhist, Hindu, and Jain texts, as they discuss the
limits of perception and the importance of context. The parable has several
variations.
Box 6.1 A definition of critical thinking
‘The intellectually disciplined process of actively and skilfully
conceptualising, applying, analysing, synthesising, or evaluating
information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief
and action. In its exemplary form, it is based on universal intellectual
values that transcend subject matter divisions: clarity, accuracy,
precision, consistency, relevance, sound evidence, good reasons,
depth, breadth, and fairness.’
From the US National Council for Excellence in Critical Thinking
https://www.criticalthinking.org/pages/defining-critical-thinking/766
(accessed April 2022).
It’s like a
thick wall
It’s like a
rope …
It’s like a
tree trunk
involves being able to gather data and interpret it. It involves the
senses: vision, touch, hearing, and smell. It requires specific
clinical knowledge, skills, and behaviours.
Critical thinking has its roots in the teaching of Socrates and is
related to logic. Logic is to do with the analysis of arguments – more
specifically the study of arguments which are made up of a set of
premises together with a conclusion. Three types of logical
reasoning are deduction, induction, and abduction (see further
resources). However, good thinking cannot be reduced to logical
thinking. Rationality is the term used by psychologists to describe
good thinking – thinking that is ‘reasonable, based on facts or
reason’ [3]. It not only encompasses logical methods of problemsolving but also incorporates our beliefs, values, goals, and context.
There are several different models of rationality [4]. The two
most relevant to medicine are epistemic (or evidential) rationality –
what is true – and instrumental rationality – what to do. Epistemic
rationality is to do with how well our beliefs are commensurate
with the available evidence. Instrumental rationality is to do with
adopting suitable means to an end given the resources available
to us. Thus, rationality in medicine is not about every decision
being ‘correct’ or error free. On the contrary, rational decision‐
making takes into account the consequences of possible errors to
aid in arriving at desirable outcomes [4]. A person’s capacity for
Knowledge
Critical
thinking
ability
Cognitive
ability
Figure 6.2 Components of rationality. *Individual characteristics include
things like cognitive style, personality, gender, age, and other variables.
Adapted from Croskerry, 2017.
Individual
characteristics*
rational thinking is influenced by several factors, illustrated in
Figure 6.2.
Dual Process Theories
In 2009, Croskerry described research on human thinking and
decision-making which provides a basic framework for understanding diagnostic reasoning [5]. Since his description of dual
process theories as applied to medicine, a dual process model has
become widely accepted as a framework with which to understand diagnostic reasoning and diagnostic error (see Figure 6.3).
However, this model is often misunderstood, so this next section
aims to describe dual process theories as applied to medicine and
then clarify some common misunderstandings.
Humans have two distinct processes when it comes to thinking
and decision-making – one that is intuitive and subconscious and
one that is analytical and conscious. This ‘dual process’ is supported by many experiments in psychology as well as functional
magnetic resonance imaging [6, 7]. These two processes are called
Type 1 and Type 2 respectively and their characteristics are listed
in Box 6.2.
Type 1 processing is intuitive and subconscious, a result of several systems in the brain that operate autonomously and in
parallel in response to their own stimuli. They are a result of:
•
Processes that are hard-wired/evolutionary (e.g., representativeness)
’Recognised‘
Clinical
presentation
Not
Figure 6.3 A simplified model of diagnostic reasoning. Adapted from
Croskerry, 2009.
Type 1
processing
Overlearning
and practice
Type 2
processing
Override
Calibration Diagnosis
Models of Clinical Reasoning 37
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Box 6.2 Characteristics of Type 1 and Type 2 processes
Type 1 Type 2
Intuitive, uses heuristics (mental
shortcuts/pattern recognition)
Automatic, pre- or subconscious
Low effort
Non-language based
High processing capacity
Highly contextualised
•
Processes that are regulated by emotions (e.g., fear of snakes
Analytical, systematic
Deliberate, conscious
High effort
Language based
Limited capacity
Decontextualised
which is evolutionary, or dislike of certain people groups, which
is learned)
•
Processes embedded through overlearning (e.g., driving)
•
Processes embedded through implicit learning (e.g., stereotyping)
Type 2 processing, on the other hand, is analytical and conscious
and serial in nature. It is often language based and uses rules. Its
most distinctive characteristic is hypothetical thinking and its
ability to override early Type 1 responses and substitute better
ones via a process of cognitive stimulation.
When you instantly recognise something because you have seen
it before, you have engaged in Type 1 processing. When you have
to go through a deliberate process in order to figure out what
something is, you have engaged in Type 2 processing. When you
think you recognise something, but then pause and say to yourself,
‘Hang on a minute, what else could this be?’ you have over-ridden
your early Type 1 response and engaged in cognitive simulation.
Different dual process theories make different assumptions
about the relationship between Type 1 and Type 2 processing,
with some assuming the two occur in parallel, others assuming
that processing is sequential, and others assuming that one or the
other is used in a given situation. Most dual process theories
assume that Type 1 processing makes use of associations that are
built up through repeated experience, while Type 2 processing can
use information that has been learned only on a single occasion.
In clinical practice, Type 1 processing accesses schemas, or patterns, based on formal and experiential learning, known as ‘illness
scripts’. According to script theory, medical knowledge is bundled
into networks that allow clinicians to integrate new information
with existing knowledge, recognise patterns and irregularities in
clinical presentations, identify similarities and differences between diseases, and make predictions about how diseases are likely
to unfold [7]. These knowledge networks become updated and
refined through further experience and learning. Type 2
processing, on the other hand, uses knowledge of rules, procedures, and linguistically coded strategies which are used to think
through problems or simulate alternatives. The knowledge, rules,
procedures, and strategies utilised by Type 2 processing have been
collectively termed ‘mindware’ and includes things like scientific
thinking, probabilistic reasoning (see Chapter 3), and logic.
We spend most of our lives using Type 1 processing in order to
conserve cognitive energy – we simply could not live our lives if
every single decision were conscious, deliberate, and effortful. We
instantly recognise a chair and understand its purpose without
thinking about it. After a while, clinical practice is no different,
but this does not mean we cannot pause to reflect on our thinking
and decision-making in the moment. In fact, engaging in reflection during diagnostic decision-making has been found to be the
most consistent and precise cognitive intervention for improving
diagnostic accuracy. The benefit of reflection is greatest when the
case is complex relative to the decision-maker [8]. Reflection can
be as simple as asking oneself, ‘What’s the evidence for this? What
else could it be?’ or listing findings that are compatible or not
compatible with each differential diagnosis, a strategy that can be
used in teaching clinical reasoning (see Chapter 10). However,
people vary in their tendency to spontaneously engage in reflection during decision-making – more of that later.
Common Misunderstandings
It is a common misunderstanding that errors in clinical reasoning
mainly arise because of ‘cognitive biases’ (heuristics gone wrong) –
a result of Type 1 processing and a failure of Type 2 processing to
interrupt and override the initial intuitive response. Humans do
indeed have an overwhelming tendency to default to a fast, loweffort mode of decision-making (what psychologists call being a
‘cognitive miser’) and this can certainly lead to error – an idea
popularised by Kahneman in his book Thinking, Fast and Slow
[9]. However, experts use Type 1 processing most of the time. For
them, it is fast and highly accurate. More generally, diagnostic
accuracy is associated with spending less time on a task, and getting clinicians to ‘slow down and be more analytical’ under experimental conditions does not improve accuracy. Mistakes can also
occur with Type 2 processing – if the relevant mindware is not
available because it has never been learned, or the relevant mindware is contaminated, then a suboptimal response is not the result
of a failure to override Type 1 processing, but the result of a mindware problem – in other words, a mistake rooted in inadequate or
faulty knowledge. Miserly Type 2 processing can also occur – the
framing effect and search satisficing (see Chapter 7) are examples
of this. Cognitive simulation takes effort, so the most easily constructed model is likely to win, especially if the person is operating
under conditions that diminish Type 2 processing, such as fatigue.
The bottom line is that no one type of processing is inherently
better than the other. Both have different functions and different
strengths and weaknesses and experts use multiple strategies
depending on the circumstances.
Tri-Process Theory
There are few differences between individuals when it comes to a
tendency to engage in Type 1 processing. But there are significant
differences when it comes to a tendency to engage in Type 2
processing. Some of these differences are to do with intelligence/
cognitive ability, aspects of the environment, e.g. time pressure, and
motivation or mood. But a person’s cognitive style – their tendency
to seek information, look for evidence, weigh things up, have an
awareness of context, and think about their own thinking – has
been found to account for significant differences in performance
38 ABC of Clinical Reasoning
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on reasoning tasks after cognitive ability has been accounted for
[10]. Previous dual process theories tended to ignore individual differences which are key to understanding why people of similar
cognitive ability vary considerably in their performance – a
phenomenon we frequently observe in clinical practice.
There is good evidence that rational decision-making often
involves three processes: intuitive (Type 1) processing which may
or may not generate a suboptimal response; analytical (Type 2)
processing which can simulate alternatives and generate a potentially better response; and reflective (also Type 2) processing
which initiates the override of a potentially suboptimal response
in the first place [11]. These different processes all rely on different types of knowledge: intuitive processing on formal and experiential knowledge tightly compiled as ‘illness scripts’; analytical
processing on medical knowledge, rules, procedures, and strategies (mindware); and reflective processing on general
knowledge, beliefs, and goals. Stanovich refers to reflective
processing as ‘the reflective mind’ which shares the same characteristics of Type 2 processing [10], while other psychologists refer
to this third process as ‘metacognition’ – thinking about one’s
own thinking. Rational decision-making can be seen as a function
of processing at both the analytical and the reflective level (see
Figure 6.4).
In clinical practice, a tri-process model is flexible depending on
the circumstances. Different clinicians reflect (or not) on different aspects of any given case, depending on their own unique
knowledge and experience and the situation in which they find
themselves [12]. Type 2 processing is optional and effortful, and
the extent to which it is engaged varies every time and individual
makes a judgement, and sometimes it may not take place at all.
There is no one set of cognitive, metacognitive, motivational, and
behavioural strategies that constitute the desirable mode of
engagement in every setting and task [13]. In clinical practice,
some situations call for rapid, good enough, low-effort responses,
and others for a more systematic, deliberate analysis of all the
available information. The challenge for clinicians is to know
when to ‘slow down when you should’ [14]. The challenge for
educators is to provide clinical environments with multiple tasks
and strategies in order to equip learners over time to be able to
reason through a variety of clinical problems as effectively as possible [12].
Errors in Thinking
Stanovich has proposed a taxonomy of thinking error types based
on his tri-process model which provides a useful model for
understanding diagnostic reasoning and diagnostic error, particularly from an educator’s perspective [15] (see Figure 6.5). This
model is entirely consistent with a number of observations in the
clinical reasoning and education literature: that expertise in medicine depends on a large and retrievable body of formal and experiential knowledge; that high levels of performance not only
require knowledge, but also motivation and metacognitive skills;
and that reasoning occurs in context, and effortful Type 2
processing is highly affected by things like distractions, fatigue,
sleep deprivation, and cognitive overload – common suboptimal
conditions under which clinicians operate.
In Figure 6.5, errors in thinking may occur because of a default
to Type 1 autonomous processing. This is more likely to occur
when the clinician is not an expert in the specific disease or presentation in question. For example, representativeness is a heuristic (mental shortcut) humans use when estimating how likely a
certain event is – they assess how similar something is compared
to an existing mental prototype. These judgemental shortcuts
generally get us where we need to go but sometimes they are
wrong. The fact that something is more representative does not
actually make it more likely [9]. For example, medical curricula,
and textbooks, often present clinical problems in a prototypical
fashion, but in the real world, clinical problems present with far
greater variety. Most people with meningitis in countries like the
USA and UK do not have neck stiffness on examination when
they first present to hospital [16]. If a clinician is seeing a patient
with headache, fever, nausea, and myalgia but no neck stiffness,
they may dismiss meningitis as a possibility because it does not fit
the prototype – even though ‘the prototype’ is in fact wrong [17].
Errors can also occur if thinking proceeds with a focal bias.
Default to Type 1 autonomous processing is not always possible,
particularly in novel situations, something which is more likely to
be the case for inexperienced clinicians. Analytic processing may
be required, but because humans have an innate tendency to be
cognitive misers, the thinking that ensues may not involve a fully
decoupled cognitive simulation. Search satisficing is a good
example of this (see Chapter 7), when we stop searching because
we have found something that fits or is convenient, instead of
’Recognised‘
Clinical
presentation
Not
recognised
Figure 6.4 Tri-process theory. Adapted from Croskerry, 2009; and Stanovich,
2011 – see references.
Type 1 processing
(intuitive)
Type 2 processing
(algorithmic)
Type 2 processing
(reflective)
Calibration Diagnosis
’Recognised‘
Clinical
presentation
Not
recognised
Figure 6.5 Taxonomy of thinking error types. Adapted from Croskerry,
2009; and Stanovich, 2011 – see references.
Type 1 processing
(intuitive)
Type 2 processing
(algorithmic)
Type 2 processing
(reflective)
Default to autonomous
processing
Serial associative
cognition with a focal
bias
Override failure
Missing mindware
Contaminated
mindware
Working diagnosis
Models of Clinical Reasoning 39
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systematically looking for the best alternative. Stanovich describes
this kind of thinking as serial and analytic (as opposed to intuitive) but relying on a single focal model (the ‘diagnosis’) that triggers all subsequent thought. There is no decoupling, no override,
no cognitive simulation (‘What else could this be?’), and no interruption of serial associative cognition.
Staying with Figure 6.5, cognitive decoupling may occur, but it
may fail to suppress Type 1 processing – what Stanovich calls
override failure. An example is denominator neglect when, statistically, x is more likely than y but, intuitively (and incorrectly) y
‘feels’ more likely. The clinician is often aware that ‘logically’ x is
the correct answer, but cannot resist choosing y. This may lead to
inappropriate selection of tests which in turn could lead to
incidental findings or false positive results, which in turn could
lead to more unnecessary investigations (see Chapter 3).
Errors can also occur with Type 2 processing when the medical
knowledge, rules, procedures, and strategies (mindware) are either
missing or contaminated. For example, if a clinician has never
been taught the principles of choosing and interpreting diagnostic
tests, a ‘positive’ or ‘negative’ result may simply be taken at face
value. Or if a clinician believes (incorrectly) that normal SpO
levels make it unlikely a patient has a pulmonary embolism, they
may dismiss pulmonary embolism as a potential diagnosis. Rules,
procedures, and strategies may also be inappropriately applied to a
patient’s presentation or clinical situation (see Chapter 5).
A tri-process model of clinical reasoning can be useful for educators in diagnosing difficulties and helping learners improve. A
metacognitive approach to instruction (e.g., helping learners
think about their own thinking by getting them to verbalise their
thinking as they work) has been shown to increase learning and
the degree to which students can transfer it to new settings (see
Chapter 10 for details on elaboration and self-explanation).
Learners can be taught to develop their own internal dialogue,
increasing their ability to monitor their own thinking and understanding [18]. However, such metacognitive skills cannot be
taught in isolation from the specific content at hand.
Expertise in Clinical Reasoning
It has been shown very clearly that experience is required to
develop expertise, but even extensive experience in a domain
does not invariably lead to expert levels of performance [19].
After years of experience in postgraduate training, most clinicians attain an acceptable level of proficiency to be able to do
most things automatically, but if they do not engage in something
called deliberate practice they simply become experienced nonexperts [20]. In Ericsson’s words, most professionals reach a
stable, average level of performance within a relatively short timeframe and maintain this mediocre status for the rest of their
careers [19] – this level of performance is sufficient a lot of the
time, but not all of the time.
Chapter 10 explains that clinical reasoning ability is highly
dependent on knowledge, knowledge organisation, and deliberate practice. It outlines what to teach and key concepts regarding
Box 6.3 Themes in the early careers of master clinicians
Theme Actions
1 Consistent
learning efforts
2 Rigorous skill
development
3 Cultivating
habits of mind
4 Working in
clinically rich
environments
2
Adapted from Murthy VK, O’Brien B, Dhaliwal G. (2018). An inquiry into
the early careers of master clinicians [21].
Spending time devoted to:
• Reading/studying
Teaching and preparing to teach
•
•
Learning by tracking patient outcomes
Spending time purposefully refining:
• Communication/consultation skills
Physical examination skills
•
•
Clinical reasoning skills
Adopting habits such as:
Having empathy towards patients
•
•
Enthusiasm for clinical medicine
Humility about one’s own knowledge and
•
clinical abilities
• Curiosity and rigorous case analysis
Spending time:
•
Working in high-volume clinical areas
Working outside one’s own comfort zone
•
•
Learning from peers (e.g., discussing cases) and
role models
how to teach, including curriculum design. This type of teaching
and learning will hopefully lead to competence in clinical
reasoning of the type required for new graduates. But what about
expertise? Further insights can be gained from an inquiry into the
early careers of master clinicians which found four overlapping
themes: 1) consistent learning efforts, 2) rigorous skill develop
ment, 3) cultivating habits of mind, and 4) working in clinically
rich environments [21]. These themes are expanded further in
Box 6.3.
We can also learn from other models of expertise which argue
that expertise should be considered from a process perspective
not an achievement perspective. What differentiates expert
behaviour from non-expert behaviour? Experts have automated
processes that were once cognitively effortful. As authors
Moulton et al. put it, surgeons perform standard operations while
talking about their tennis game, internists diagnose a patient
from the end of the bed, emergency physicians immediately initiate multiple tasks in a trauma victim, and family doctors recognise chicken pox in an instant. But when something unexpected
occurs, or something does not quite fit, will the clinician in
automatic mode recognise it, or will that clinician plough
through, oblivious to the situation’s uniqueness and unaware of
its consequences? [14] This, they say, illustrates one vital aspect
of expert judgement: slowing down when you should.
Considering expert judgement from this perspective allows for
fluctuations in individual performances and also explains why a
resident may behave in an expert manner whereas a more senior
physician may not.
-
40 ABC of Clinical Reasoning
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Summary
Clinical reasoning is highly dependent on different types of
knowledge, but good decision-making often requires other
things: a capacity for rational thinking (see Figure 6.2), motivation (including empathy), effort, metacognitive skills, and optimal
ambient conditions.
While cognitive models of clinical reasoning are useful for educators, developing expertise in clinical reasoning needs to go
beyond this and different perspectives are important for understanding, teaching, and learning clinical reasoning.
Developing expertise in clinical reasoning takes years, but it
can be deliberately nurtured by teaching the right content,
providing the breadth and depth of experience required with
coaching and feedback, and explicitly letting learners know what
strategies they can employ in order to become excellent
clinicians.
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Oxford: OUP, 2009.
12. Eva K. (2004). What every teacher needs to know about clinical
reasoning. Medical Education; 39: 98–106.
13. Kaplan A. (2008). Clarifying metacognition, self-regulation, and
self-regulated learning: what’s the purpose? Educational Psychology
Review; 20: 47.
14.
Moulton CE, Regehr G, Mylopoulos M et al. (2007). Slowing down when
you should: a new model of expert judgment. Academic Medicine;
82(10): S109–S116.
Stanovich KE. Distinguishing the reflective, algorithmic, and autonomous
15.
minds: is it time for a tri-process theory? In: Evans J and Frankish K
(Eds). In two minds: dual processes and beyond. Oxford: OUP, 2009.
Thomas KE et al. (2002). The diagnostic accuracy of Kernig’s sign,
16.
Brudzinski’s sign, and nuchal rigidity in adults with suspected
meningitis. Clinical Infectious Diseases; 35(1): 46–52.
17.
Manzoor F and Redelmeier DA. (2019). The perils of teaching medical
triads. Medical Education; 53: 110–112.
Bransford JD, Brown AL and Cocking RR (Eds). How people learn: brain,
18.
mind, experience and school. Washington DC: National Academies Press,
2000.
19. Ericsson KA. (2004). Deliberate practice and the acquisition and
maintenance of expert performance in medicine and related domains.
Academic Medicine; 79(10): S70–S81.
20. Croskerry P. (2018). Adaptive expertise in medical decision making.
Medical Teacher; 40(8): 803–808.
21. Murthy VK, O’Brien B and Dhaliwal G. (2018). An inquiry into the early
careers of master clinicians. Journal of Graduate Medical Education;
10(5): 500–506.
Further Resources
1. Zaharias G. (2018). What is narrative-based medicine? Narrative-based
medicine 1. Canadian Family Physician; 64(3): 176–180.
2. Lee SF. Logic: a complete introduction. Teach Yourself, 2017.
3. Fish D and de Cossart L. Developing the wise doctor. Royal Society of
Medicine Press, 2007.
CHAPTER 7
https://t.me/medicina_free
Cognitive Biases
Nicola Cooper
OVERVIEW
• Biased decision-making significantly impacts individuals, institutions, and society as a whole
The extent to which cognitive biases contribute to diagnostic
•
errors in medicine is debated
• There are different reasons why cognitive biases may occur
• Several different cognitive biases have been described
• Expert intuition plays an important role in expert professional
practice
Introduction
Chapter 6 described how humans have two distinct processes
when it comes to thinking and decision-making – one that is intuitive and subconscious (Type 1 processing) and one that is analytical and conscious (Type 2 processing). Type 1 processing makes
use of associations that are either learned or inculcated by evolutionary processes. Many of our decisions are made through serial
associations that do not involve conscious, effortful thinking –
Croskerry gives the example of performing a well-learned act such
as driving a car [1]. Much of this serial association is guided by
heuristics (from the ancient Greek ‘I find, discover’) – simple, efficient rules or mental shortcuts. These rules work well under most
circumstances, but in some cases can lead to systematic errors
known as cognitive biases.
Since the 1970s, cognitive psychologists have examined the
influence of heuristics on human decision-making and this has
led to an explosion of what is known as the ‘heuristics and biases’
literature. Psychologists Tversky and Kahneman defined biased
judgement and decision-making as that which systematically
deviates from the prescriptions of objective standards such as
facts, rational behaviour, statistics, or logic [2]. The reason why
heuristics and biases are of such interest to psychologists is
because biased decision-making significantly impacts
individuals,
institutions, and society as a whole – ranging from whether to get
vaccinated, grant someone parole, or deciding whether Iraq has
weapons of mass destruction [3].
The topic of cognitive biases in clinical reasoning, however,
is controversial. This is partly because, as mentioned in Chapter
6, there are several key fallacies in the received view of dual process theories, including the beliefs that 1) Type 1 processes are
always responsible for cognitive bias and Type 2 processing is
always responsible for correct responses, 2) Type 1 processing
is contextualised and Type 2 processing is abstract, and 3) fast
processing is indicative of Type 1 processing [4]. It is also because
studies in the psychology literature mainly involve general problems specifically designed to induce biases in non-experts (see
Box 7.1). There have been very few studies in medicine and
none to date has been able to demonstrate that teaching about
cognitive biases reduces diagnostic error. This may be in part
because of what we know from non-medical education – metacognitive skills cannot be taught in isolation from the specific
content at hand and attempts to teach them as generic may lead
to a failure to transfer [5].
Box 7.1 A problem designed to induce heuristics and bias
An individual has been described by a neighbour as follows: ‘Steve
is very shy and withdrawn, invariably helpful but with little interest
in people or in the world or reality. A meek and tidy soul, he has a
need for order and structure, and a passion for detail.’ Is Steve more
likely to be a librarian or a farmer?
Answer: there are more than 20 male farmers for each male
librarian in the United States, so Steve is more likely to be a farmer.
But participants in this experiment ignore the relevant statistical
facts and rely exclusively on resemblance.
From Kahneman D. (2011). Thinking, Fast and Slow. Penguin Books,
London.
ABC of Clinical Reasoning, Second Edition. Edited by Nicola Cooper and John Frain.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
42 ABC of Clinical Reasoning
https://t.me/medicina_free
There is definitely agreement that cognitive biases exist in
medicine, but disagreement as to whether they are a significant
source of diagnostic errors compared with knowledge deficits.
Norman et al. concluded it is likely that both cognitive biases and
knowledge deficits contribute to errors. However, the existing literature is simply insufficient to address the interplay and relative
contributions of each [6].
This chapter will cover cognitive biases that are commonly
encountered in clinical practice. The next chapter on situativity
and human factors discusses the limitations of human performance
further, and Chapter 9 explores cognitive strategies to avoid error.
Case History
A 75-year-old woman presented to hospital at around 5:00 p.m.
with breathlessness. She had been told by her oncologist a few
weeks before that she was anaemic, and to report to hospital if
she got breathless or dizzy in case she needed a blood transfusion. Her haemoglobin at presentation was 84 g/L which was
unchanged from previously. Her only past medical history was
breast cancer for which she had had a mastectomy and was
undergoing adjuvant chemotherapy. She was usually fit and
independent and was not taking any regular medication apart
from anti-emetics.
On examination, her vital signs were normal. Examination of
the chest, heart, and abdomen was normal. Her 12-lead electrocardiogram (ECG) and chest X-ray were normal. Apart from the
haemoglobin of 84 g/L, her other blood tests (white cell count,
platelets, electrolytes, calcium, and liver function tests) were
normal. The emergency department doctor diagnosed breathlessness due to anaemia and arranged for her to be admitted for a
blood transfusion. The junior doctor on the acute medical unit
also assessed the patient and said the same thing. At 11:00 p.m.
the senior resident reviewed the patient’s case and said the same
thing. Someone had requested a high sensitivity troponin T in the
emergency department because the patient had mentioned brief
palpitations, although she never had any chest pain. The troponin
result was 126 ng/L (reference range 0–13 ng/L). The senior doctor therefore requested a repeat ECG and repeat troponin.
What are your thoughts at this point?
The next morning another senior resident and an oncology
nurse specialist saw the patient and made preparations for a blood
transfusion. Then the medical consultant saw the patient.
Something did not seem quite right – the patient’s haemoglobin
was 84 g/L when she did not have symptoms, so why was she
breathless now? And what was this troponin result all about? It
seemed very unlikely she had an acute coronary syndrome since
she never had any chest pain and her 12-lead ECGs were normal.
On further questioning, the patient said she was in the supermarket the day before when she suddenly felt lightheaded, with
associated palpitations and breathlessness. This lasted around 10
minutes and then settled down, but she had ‘not felt quite right’
since. An urgent computed tomography pulmonary angiogram
was requested. This showed bilateral pulmonary emboli with
right heart strain.
Analysis
Diagnostic momentum (see Figure 7.1) is the tendency for a diagnosis to ‘stick’ despite a lack of supporting evidence. It involves several intermediaries – often starting as an opinion which may not
even be medical, for example, the patient or a relative – and is passed
with increasing certainty from one person to the next. Diagnostic
labels become particularly sticky if a specialist has seen the patient.
However, there were several other things going on in this case,
including:
•
Anchoring
•
Search satisficing
•
Confirmation bias
Anchoring
Anchoring describes the common human tendency to rely too
heavily on the first piece of information offered (the anchor)
when making decisions. The initial piece of information (in this
case, ‘I was told if I get breathless to come to hospital because it
means I need a blood transfusion’) is used to make subsequent
judgements. Once an anchor is set, other judgements are made by
adjusting away from the anchor, and there is a bias towards interpreting other information around it. Businesses use anchoring all
the time – the ‘recommended retail price’ is an anchor. Salespeople
use anchors to open negotiations. Several experiments have demonstrated the anchoring effect. In one example, estate agents were
asked to estimate the value of a house. Beforehand they were
given a randomly generated listed sales price. The higher the
listed sales price, the higher they valued the property, although
they denied being influenced by the anchor [7]. Lots of studies
show that anchoring is very difficult to avoid, although experts
may be more resistant to anchoring bias in their particular field.
Search Satisficing
Search satisficing is a term derived from the words ‘satisfy’ and ‘suffice’ – when we stop searching because we have found something
that fits or is convenient, instead of systematically looking for the
best alternative, which involves more effort. Satisficing is beneficial
in everyday life – for example, when choosing from an extensive
menu at a restaurant, or when there is an unlimited amount of
information available and it is necessary to eliminate options and
make a decision efficiently. However, in groups satisficing can be
detrimental – for example, when people settle for a solution
everyone can agree on even though it may not be the best one.
Wife:
‘I’m worried
you’re
having a
heart attack’
Figure 7.1 Diagnostic momentum. ACS=acute coronary syndrome.
Patient:
‘It feels like
I’m having a
heart attack’
Paramedic:
‘52-year-old
male with
possible
ACS’
Nurse:
‘You know
that man
with ACS in
cubicle 12?’
Doctor:
Documents
‘possible ACS’
in notes
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