Analytical versus non-analytical clinical reasoning

04/20/23

Alireza Monajemi, MD-PhDPhilosophy of science department

Institute for Humanities and Cultural Studies

Thursday, April 20, 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

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.

The psychological mechanisms underlying such reasoning tendencies are not always

available to introspection

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

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

04/20/23

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.

careful analysis of the relation between signs and symptoms

and diagnoses are the hallmark of clinical expertise

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

clinical teacher admonishes a student to ‘be objective’ and

‘carefully consider all the evidence available before

generating diagnostic hypotheses’.

Analytic process in clinical 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

• close to the evidence-based medicine movement

• Bayes’theorem or regression analyses

Non-analytical reasoning

• Solving problems in the light of prior knowledge and belief

• the evidence that clinicians use non-analytic processes in reaching diagnostic decisions is indisputable

Non-Analytic process in clinical reasoning

It has been argued that the ability to use non-analytic bases of clinical decision

making increases with expertise

as a result, the use of pattern recognition

should not be advocated among medical students

for fear ofpotentially grim consequences

Non-analytic bases of judgment are not inferior to more analytic forms of

reasoning

clinical teachers should inform their students that similarity to past instances can serve as a useful guide.

excessive reliance on non-analytic approaches to clinical reasoning can be a source of

diagnostic error

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

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

A combined model of clinical reasoning

A critical factor, however,

was that the analyticprocessing should be carried out in close

temporal relation to performing the actual task of diagnostic

judgment.

• 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

These two reasoning are complementary contributors to

the overall accuracy of the clinical reasoning process,

each influencing the other

combined instruction resulted in greater

diagnostic accuracy than did purely analytic

instructionThursday, April 20, 2023 EBM- weekly conference

failure to perform an analytic confirmation

results in premature closure

“good problem solvers”=

“good coordinators” of analytic and non-analytic

processing

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

Dual process theory

Two different kinds of cognitive processing

affect inferences and judgments.

Critical thinking in medicine is now called

reflective practice in medicine

Reflective practice in medicine

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.

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.

• 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

Metacognition

Openness

Induction Deduction Test

Hypothesis formation(DDx)

Backward reasoning

Hypothesis evaluation

Reflective practice &

medical errors

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.

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.

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.

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.

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.

Confirmation bias

تمایل به جستجوی عًالئم و نشانه های تائید کنندۀ\ تشخیص و بی توجهی به سایر تشخیص ها.

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

Analytical versus non-analytical clinical reasoning

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