Psychological Perspectives on Medical Decision Making and Problem Solving

Question 1

How many diagnosis is missed or delayed

Answer 1

Diagnosis missed or delayed in 5% - 14% of acute hospital admissions

Question 2

What are the diagnostic error rates in autopsy studies

Answer 2

Autopsy studies confirm diagnostic error rates of 10% - 20%

Question 3

how many patients do not receive evidence based care

Answer 3

Up to 45% of patients (acute and chronic) do not receive evidence based care

Question 4

how many drugs and investigations are unnecessary

Answer 4

Between 20% - 30% of investigations and drugs administered are potentially unnecessary

Question 5

What do half of errors involve in terms of decision making, investigators and drugs and diagnosis

Answer 5

Almost half of these errors involved reasoning or decision quality (failure to elicit, synthesise, decide or act on clinical information)

Question 6

How many diagnosis that clinicians were certain of were proven wrong at autopsy

Answer 6

in a study 40% of diagnoses about which clinicians were certain were proven wrong at autopsy

Clinicians may stick to a diagnosis even when colleagues or decision tools suggest they’re wrong

Question 7

What did the department of health 2000a report that

Answer 7

• Staff didn’t know what to report or why
• If the patient was ‘unharmed’ then the error didn’t matter
• Staff felt too busy to report
• There was a lack of feedback when errors were reported
• There was a fear or disciplinary action or litigation (for self or colleagues)

Question 8

what are the explanatory models of human error

Answer 8

• Persons approach

- Weakness of the person approach

Question 9

Describe the explanatory models of human error

Answer 9

Person approach

• Healthcare professional is responsible
• Forgetfulness, negligence, poor motivation, carelessness, inattention
• Also known as ‘active errors

Weakness of the person approach

• Prevents analysis of what went wrong – so no opportunity to change it
• Failure to recognise that most mistakes happen in patterns
• Suggests that mistakes are only made by ‘bad’ doctors

Question 10

What does the system approach that

Answer 10

Mistakes are inevitable because humans are fallible

Errors are consequences rather than causes - unworkable procedures, inadequate equipment, fatigue, understaffing

Question 11

Describe a model inductive clinical reasoning versus the hypothetico-deductive model

Answer 11

Model Inductive

• initial collection of information from history and examination
• series of logical problem solving steps (Algorithms)
• diagnosis

Hypothetico-Deductive

• collection of information
• generation of hypothesis
• analysis of information to confirm or refute the hypothesis
• diagnosis

Question 12

What are heuristics

Answer 12

Cognitive shortcuts /decisional shortcuts

Question 13

What is type 1 thinking

Answer 13

Type 1 thinking is fast, intuitive, unconscious thought, Most everyday activities

Question 14

What is type 2 thinking

Answer 14

System 2 is the deliberate type of thinking involved in focus, deliberation, reasoning or analysis – such as calculating a complex math problem,

Question 15

describe pattern recognition

Answer 15

• quick

- intuitive

Question 16

What is pattern recognition based of of

Answer 16

Based on experience of lots and lots of cases

• Means that atypical presentations can still be spotted
• That the experienced doctor will know what additional information is needed to complete the clinical picture

Question 17

What are cognitive biases

Answer 17

Systematic and predictable errors in judgement, resulting from reliance on heuristics

Question 18

Describe availability bias

Answer 18

Things seem more likely if they readily come to mind

So a disease seen recently will seem more likely

Question 19

What is the problem with representativeness bias

Answer 19

• Diagnosis seems more likely based on how similar the characteristics are to typical cases
• Only looks for prototypical manifestations of disease

Question 20

Describe what anchoring is

Answer 20

Perceived probability of event or diagnosis based on one trait or piece of information
- don’t look for or consider other information

Question 21

What is diagnosis momentum

Answer 21

• Once labels are attached to patients they get stickier and stickier
• Because the staff and family around the patient also use the diagnosis it becomes definite
• And it’s hard to go back and change it so all other possibilities are excluded

Question 22

What is fundamental attribution error

Answer 22

The tendency to blame people for their illness rather than the circumstances

This occurs particularly for psychiatric patients, minorities, those with substance abuse issues and other marginalised groups

Question 23

What is commission bias

Answer 23

• The tendency to action rather than inaction
• This can be problematic in many ways – prescribing tests or medication which are not necessary
• It’s more common in over-confident doctors (people?)
• But it’s also a function of what patients expect of medical encounters.

Question 24

How do you get rid of cogntivie bias

Answer 24

Develop insight/awareness

Consider alternatives

Metacognition (reflection)

Decrease reliance on memory

Specific training (like this lecture!)

Simulation

Make the task easier

Minimise time pressures

Establish accountability and possibility of feedback

Question 25

What makes up cognitive biases

Answer 25

``` Availability Representativeness Anchoring Diagnosis Momentum Fundamental Attribution Error Commissioning bias ```

Question 26

What is the role of the patient

Answer 26

- Shared decision making

Question 27

What is the role of the doctors

Answer 27

The nature of clinical problems – biomedical or psychosocial? Existing knowledge of the patient Stereotypes Mood Age, gender, weight, geographical location and own behaviour