Conscious thought beats deliberation without attention in diagnostic decision-making: at least when you are an expert

Mamede, Sílvia; Schmidt, Henk G.; Rikers, Remy M. J. P.; Custers, Eugène J. F. M.; Splinter, Ted A.W.; Saase, Jan L.C.M. van

doi:10.1007/s00426-010-0281-8

Cited by 135 publications

(141 citation statements)

References 29 publications

(49 reference statements)

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“…In contrast, higher-scoring clinicians may tend to overthink patients' presentation, alternative diagnoses or potential complications so that they rationalize why antibiotics might be indicated. In medical decision-making, reflective reasoning is useful, but has the potential to lead to loss of efficiency (12,13). For making diagnostic decisions, evidence is conflicting between the relative benefits and balance between intuitive or reflective clinical decisions (14,15).…”

Section: Discussionmentioning

confidence: 99%

Cognitive reflection and antibiotic prescribing for acute respiratory infections

Pineros

Doctor

Friedberg

et al. 2016

FAMPRJ

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Background. Variation in clinical decision-making could be explained by clinicians' tendency to make 'snap-decisions' versus making more reflective decisions. One common clinical decision with unexplained variation is the prescription of antibiotics for acute respiratory infections (ARIs). Objective. We hypothesized that clinicians who tended toward greater cognitive reflection would be less likely to prescribe antibiotics for ARIs. Methods. The Cognitive Reflection Test (CRT) is a psychological test with three questions with intuitive but incorrect answers that respondents reach if they do not consider the question carefully. The CRT is scored from 0 to 3, representing the number of correct answers. A higher score indicates greater cognitive reflection. We administered the CRT to 187 clinicians in 50 primary care practices. From billing and electronic health record data, we calculated clinician-level antibiotic prescribing rates for ARIs in 3 categories: all ARIs, antibiotic-appropriate ARIs and non-antibiotic-appropriate ARIs. Results. A total of 57 clinicians (31%) scored 0 points on the CRT; 38 (20%) scored 1; 51 (27%) scored 2; and 41 (22%) scored 3. We found a roughly U-shaped association between cognitive reflection and antibiotic prescribing. The antibiotic prescribing rate for CRT scores of 0, 1, 2 and 3 for all ARIs (n = 37 080 visits) was 32%, 26%, 25% and 30% (P = 0.10); for antibiotic-appropriate ARIs (n = 11 220 visits) was 60%, 55%, 54% and 58% (P = 0.63); and for non-antibiotic-appropriate ARIs (n = 25 860 visits) was 21%, 17%, 13% and 18%, respectively (P = 0.03). Conclusions. In contrast to our hypothesis, there appears to be a 'sweet-spot' of cognitive reflection for antibiotic prescribing for non-antibiotic-appropriate ARIs. Differences in clinicians' cognitive reflection may be associated with other variations in care.

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Section: Discussionmentioning

confidence: 99%

Cognitive reflection and antibiotic prescribing for acute respiratory infections

Pineros

Doctor

Friedberg

et al. 2016

FAMPRJ

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“…Several studies have demonstrated improved diagnostic accuracy when analytic reasoning and non-analytic reasoning are combined. 2,3 It behooves individual clinicians to develop flexibility in their analytic approaches by Bpracticing^the various clinical reasoning strategies. 2 This patient presented a diagnostic dilemma, given the limited history and presence of two seemingly unrelated syndromes (encephalopathy and hypotension with hypothermia).…”

Section: Discussionmentioning

confidence: 99%

Exercises In Clinical Reasoning

et al. 2015

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A 44-year-oldwoman with a history of cerebral palsy, intellectual disability, seizure disorder, and hypothyroidism was brought to the emergency department from her group home for increasing lethargy over the past day. At baseline she was bedbound, nonverbal, and did not follow commands. Her aide reported difficulty feeding her that morning. The patient's family had recently noted abnormal twitching movements and occasional lateral neck movements to the right during eating, which were unlike her usual seizures. Review of systems was otherwise negative. In the emergency department, she was hypothermic (T 95.3°F) and hypotensive (BP 73/54 mmHg) with a heart rate of 80 beats/min.The combination of hypotension and hypothermia brings to mind several possibilities, including sepsis, myxedema, or a central nervous system disorder affecting the hypothalamic pituitary axis, the area responsible for temperature regulation. The abnormal twitching movements could be a manifestation of her preexisting seizure disorder or possibly myoclonic jerks due to a toxic or metabolic process affecting the brain.The discussant quickly generates two differential diagnoses: one for hypotension and hypothermia and the other for abnormal twitching movements. This rapid generation of the differential diagnosis is characteristic of non-analytic reasoning or pattern recognition.The patient had a long-standing history of generalized tonic-clonic seizures occurring twice weekly on average. Three weeks ago she was hospitalized with hypothermia and hypotension, and was treated for a presumed urinary tract infection (UTI) (although cultures were negative). During that hospitalization she experienced an episode of status epilepticus, prompting addition of valproate to her anticonvulsant regimen. At that time, a morning serum cortisol level was 8.5 mcg/dL.Given her recent hospitalization, UTI or another infection could be responsible for her recurrent hypotension and hypothermia. However the negative urine culture calls into question the previous diagnosis of UTI. Noninfectious causes of hypotension and hypothermia, including adrenal insufficiency or hypothyroidism, are also possible. The serum cortisol level, while in the normal range, does not eliminate adrenal insufficiency from consideration, particularly since the patient is acutely ill (which should elevate cortisol levels). A normal response to adrenocorticotropic hormone (ACTH) administration would be preferred to exclude that diagnosis.After obtaining further data, the discussant uses analytic reasoning to interpret the normal cortisol level as relatively low in the setting of stress physiology. The cognitive psychology literature has described two types of thinking: non-analytic (i.e., fast, subconscious, intuitive) and analytic (i.e., slow, effortful, conscious). This dual process theory has been used to describe clinical reasoning. Experienced clinicians seamlessly transition between non-analytic and analytic reasoning in making diagnoses. Unfortunately, how clinicians apply and switch bet...

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“…The cognitive psychology literature supports the sequential inclusion of non-analytic and analytic reasoning in all cases, even straightforward ones. 8,9 In this example, it took the blood culture results to lift the discussant's anchor, which was initially fixed on a viral syndrome. Analytic reasoning can serve as a cross-check (e.g., is the diagnosis adequate?…”

Section: Discussionmentioning

confidence: 99%