SPECIAL CASE OF SCIENTIFIC IC REASONING? THEORY AND PRACT CTIC - - PowerPoint PPT Presentation

CLIN INICAL DECISION MAKING AS A SPECIAL CASE OF SCIENTIFIC IC REASONING? THEORY AND PRACT CTIC ICAL IM IMPLIC ICATIONS FOR MEDIC ICAL EDUCATION

I serve as Board Director of Instruct AG (CASUS) in Munich, Germany) and hold shares of this company. Instruct AG is a LMU spin-off for-profit company.

Disclosure sclosure Note te

• Clinical reasoning and diagnostic

competence: definitions and context

• System 1 and 2 and beyond
• Error reduction a key goal of diagnostic

competence – some study results

• Clinical decision making as a special case of

scientific reasoning? Proposal of a model

• Summary

Ou Outline line

Clinical Reasoning Clinical Cognition Diagnostic Reasoning Clinical Problem Solving Medical Problem Solving Clinical Decision Making …

The thinking and/or decision-making processes that are used in clinical practice

(Higgs and Jones 2000, Edwards et al 2004)

Defi finition Dia iagnosing and Dia iagnostic competence

Diagnosing is the purposeful collection and integration of information [for the purpose of uncertainty reduction] to make medical decisions. Diagnostic competence is demonstrated on the basis of diagnostically relevant knowledge and diagnostic skills by

• the accuracy of the diagnosis
• the critical consideration of effectiveness (expected value in terms of

uncertainty reduction) and

• the efficiency (the necessary expenditure for the uncertainty reduction).

Helmke 2010; Zentralantrag DFG-Forschergruppe FOR 2385, 2016

Clinical nical Re Reasoning

• ning – Cont

ntext ext Dependence? endence?

Kiesewetter & Fischer 2014

Mental Processes: Permanent “dual processing” of analytic and non-analytic thinking (“systems 1 and 2“)

Eva K Med Edu 2005, Norman G Med Edu 2007, Norman G Med Edu 2010

Ment ntal al Proce cess sses es in Cl Clini nical cal Reasoning: soning: Permanent “dual processing” of analytical and non-an analy alyti tica cal th thinking nking (Sy Syst stems ems 1 a 1 and d 2) 2)

Eva K Med Edu 2005, Norman G Med Edu 2007, Norman G Med Edu 2010

Syste stem 1: non

• n-analyt

analytical ical fast, impulsive, unconscious match to prior examples stored in memory (pattern recognition)  Influenced by the representativeness of the new problem and the availability of prior similar cases Syste stem 2: anal alytica ytical slow, logical, conceptual, amounting to the logical application of “rules” (hypothetical- deductive)  Heavy load on working memory, which has real limitations in speed and size

Singh H, et al. BMJ Qual Saf 2014

Estimate of Diagnotic errors for Adult Outpatients in the US: About 5%

• r 12 Millons Adults per Year!

Diag agnos nostic tic Errors rs in Inte ternal rnal Medici dicine: ne:

Graber ML Arch Int Med 2005

228 syste tem m rela lated ed factors

• rs

technical failure, equipment problems, teamwork, supervision, management, coordination of care, expertise unavailable, policy/procedures, …

320 cogniti itive ve factor tors 11 faulty knowledge 45 faulty data gathering 159 faulty information processing 106 faulty verification 39 premature closure (most frequent cognitive error)

How could we better understand and

• perationalize diagnostic competence

to design educational interventions and ultimately reduce errors?

Conceptual Knowledge

• Basic concepts

Procedural knowledge Strategical

• Problem-solving

strategies Conditional

• Rationale for a

procedure

(Paris, Lipson, & Wixson, 1983; van Gog, Paas, & van Merrienboer, 2004) (Stark, Kopp, & Fischer M., 2011)

Scientific knowledge Individual experience

Op Operat erationaliz ionalizin ing g Di Diagn gnostic

• stic Co

Comp mpetenc etence

Schmidmaier et al. BMC Med Edu 2013

Schmidmaier et al. BMC Med Edu 2013

Onli line ne Learning rning Envir viron

• nme

ment: nt: Case se Exampl mple e

Exam ampl ple e with thou

• ut

t error

• r and

d elabo borate rate feedb dback ck from

• m expe

pert rt

Medical Education 2008

Kiesewetter et al. PLOSone 2013

Mod

• del

l für com

• mpl

plex x pr prob

• blem

em-solving

• lving in Medicine

icine

(modifi fied d from Schoenfe enfeld ld) Kiesewetter et al. PLOSone 2013

Cognitive Action Operationalised definition Denomination Retrieve information; read Analysis Analyse information; generate differential diagnostic ideas Exploration Associate, compare, vaguely propose strategies how to understand the problem Plan Generate plans, weigh up these plans against each other, decide on a plan Implementation State and justify one definite plan; request certain additional information and/or examinations Evaluation Verify or dismiss hypotheses with regard to new information or examination results; evaluative thinking Representation Inner representation of the case; statement of the situation as far as it is summarized in the mind of the student Integration Decision for one working diagnosis, differential diagnoses and/or therapy

Kiesewetter et al. PLOSone 2013

Incomplete Complete

Incorrect solution Correct solution Incomplete model 26/29; 90% 3/29; 10% 29 cases; 44% Complete model 13/37; 35% 24/37; 65% 37 cases; 56% 39/66; 59% 27/66; 41%

Kiesewetter et al. PLOSone 2013

Cl Clinica nical Reas asoning

• ning – a Sp

Speci cial al Ca Case se of S f Sci cien entifi tific c Reasoning soning and d Ar Argumenta mentati tion?

• n?

“Scienfic reasoning (…) includes the thinking and reasoning skills involved in inquiry, experimentation, evidence evaluation, inference, and argumentation that supports the formation and modification of concepts and theories about the natural and social world.” Bao et al., 2009, Science

Use Underst erstanding anding

On One-dime dimensional sional Mo Mode del

Use Underst erstanding anding

Donald E. Stokes, Pasteur's Quadrant – Basic Science and Technological Innovation, Brookings Institution Press, 1997

Two-dimens dimension ional al Mo Mode del

Donald E. Stokes, Pasteur's Quadrant – Basic Science and Technological Innovation, Brookings Institution Press, 1997

?! ?!?

Two-dimens dimension ional al Mo Mode del: l: Fou

• ur

r Quadrants drants

Problem identification Questioning Hypothesis generation Construction of artefacts Evidence generation Evidence evaluation Drawing conclusions Communica- tion/ Scrutinizing

Epi pistem stemic ic act ctivities ities fo for reasoning soning

• 1. Problem Identification
• 2. Questioning
• 3. Hypothesis generation
• 4. Construction of artefacts
• 5. Evidence generation
• 6. Evidence evaluation
• 7. Drawing conlcusions
• 8. Communcation/Scrutinizing

Artefact‐centered scientific Reasoning (Pasteur’s quadrant

• f use-inspired

basic research)

Advancing theory- building about natural and social phenomena (Bohr’s quadrant

• f basic research)

Science-based reasoning in practice (Edison’s quadrant

• f applied research)

Clinical Reasoning Modelle

PhD-Thesis Ch. Strobel 2016

Knowledge Mot Model of Clinical Reasoning (Charlin et al., 2012) Model of Clinical Reasoning (Bowen, 2006) Model of Scientific Reasoning (Fischer et al., 2014) Meta -cognition Context Experience Final

representation

• f the problem

Dynamic representation

• f the problem

Inital representation

• f the problem

Patient’s history Data acquisition Accurate problem representation

Generation

• f hypothesis

Search for and selection of illness script Diagnosis

Communcation Conclusions Evidence Evalutation Generating Evidence Constructing Artifacts Generating Hypothesis Formulating Questions Problem Identification

• Clinical reasoning is multi-contextual and

multifacetted

• Diagnostic competence is a relevant part and

measurable contruct of clinical reasoning

• Erroneous case examples and elaborate feedback

have potential to improve diagnostic competence

Summ mmary ary (1 (1)

• The cognitive part of clinical reasoning is a form of

problem-solving

• The completeness of a problem-solving process

predicts diagnostic accuracy

• Clinical reasoning may ideally be an example of

science-based reasoning in practice (Edison’s quadrant of applied research)

Summ mmary ary (2 (2)

Many thanks for your attention!

martin.fischer@med.uni-muenchen.de

Those who can’t do teach. Those who can’t teach teach how to teach. Those who can’t teach how to teach do research on teaching.

adapted from Bernhard Shaw The doctor's Dilemma 1906