Comments on 'Clinical decision making: An emergency medicine perspective' [1] (multiple letters) (original) (raw)
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Mental Processes in Emergency Medicine
2019
In Chap. 2 of this book, we discuss that cognitive schemas determine what are the information elements that must be processed with more or less effort. Chapter 3 builds forth on that notion: the more developed and automated our cognitive schemas about a particular type of problem, the easier we can recognise problem states and possible solutions. This allows us to process routine information such as fixed procedures with less effort so that we have more working memory capacity available for what needs to be processed with more effort. This chapter applies these principles to emergency medicine. Emergency medicine involves people working in teams to assist those in need of immediate medical attention. Those who work in an emergency medicine department have to make rapid decisions under time pressure, stress and uncertainty as well as manage teamwork and organisational processes. This chapter focuses on the mental processes employed by emergency medicine practitioners when doing their...
International Journal of Emergency Medicine
Background: General medicine commonly adopts a strategy based on the analytic approach utilizing the hypothetico-deductive method. Medical emergency care and education have been following similarly the same approach. However, the unique milieu and task complexity in emergency care settings pose a challenge to the analytic approach, particularly when confronted with a critically ill patient who requires immediate action. Despite having discussions in the literature addressing the unique characteristics of medical emergency care settings, there has been hardly any alternative structured mental model proposed to overcome those challenges. Methods: This paper attempts to address a conceptual mental model for emergency care that combines both analytic as well as non-analytic methods in decision making. Results: The proposed model is organized in an alphabetical mnemonic, A-H. The proposed model includes eight steps for approaching emergency cases, viz., awareness, basic supportive measures, control of potential threats, diagnostics, emergency care, follow-up, groups of particular interest, and highlights. These steps might be utilized to organize and prioritize the management of emergency patients. Discussion: Metacognition is very important to develop practicable mental models in practice. The proposed model is flexible and takes into consideration the dynamicity of emergency cases. It also combines both analytic and non-analytic skills in medical education and practice. Conclusion: Combining various clinical reasoning provides better opportunity, particularly for trainees and novices, to develop their experience and learn new skills. This mental model could be also of help for seasoned practitioners in their teaching, audits, and review of emergency cases.
Emerging paradigms of cognition in medical decision-making
Journal of Biomedical Informatics, 2002
The limitations of the classical or traditional paradigm of decision research are increasingly apparent, even though there has been a substantial body of empirical research on medical decision-making over the past 40 years. As decision-support technology continues to proliferate in medical settings, it is imperative that ''basic science'' decision research develop a broader-based and more valid foundation for the study of medical decision-making as it occurs in the natural setting. This paper critically reviews both traditional and recent approaches to medical decision making, considering the integration of problem-solving and decision-making research paradigms, the role of conceptual knowledge in decision-making, and the emerging paradigm of naturalistic decisionmaking. We also provide an examination of technology-mediated decision-making. Expanding the scope of decision research will better enable us to understand optimal decision processes, suitable coping mechanisms under suboptimal conditions, the development of expertise in decision-making, and ways in which decision-support technology can successfully mediate decision processes. Ó
Cognition Factors and Decision Making in Critical Care Environments
2008
This panel focuses on cognitive factors in decision making in the critical care environment. Critical care environments such as the ER and ICU are distributed systems that are composed of human and artificial agents distributed across internal and external representations, across team members, and across time and space. Critical care clinicians perform lifecritical tasks that require acquisition, processing, transmission, distribution, integration, search, and archiving of significant amount of data in such a distributed environment in a timely manner. Understanding the cognitive factors in decision making in this type of environment is important for the improvement of healthcare quality and patient safety. Zhang will first introduce the theoretical framework of distributed cognition. Patel will then present cognitive studies of medical errors in the critical care environment. From the clinical perspective, Shabot will present studies of information management in the ICU. Rucker will respond to the three presentations. Finally, Shortliffe will summarize the presentations by the four speakers and coordinate the dialog with the audience.
Decision making in the emergency care unit: a study on meta-cognitive awareness
Professionals who are faced with emergency situations daily during their work can rely on three different ways of thinking. They can base their judgments and decisions on intuition. Alternatively they can apply heuristic strategies, which offer simple procedures to simplify situations and find satisfactory solutions. Finally, they can reflect analytically. The optimal approach would be a flexible use of these three systems, since it enables doctors to activate the system that is more relevant to the given situation and eventually to pass to another system when they realize that the previous one is inadequate. Metacognitive competence is required in order to identify the mental system that is more relevant to a specific case. This competence consists in the ability to self-regulate cognitive processes in order to match the specific needs of the moment. To do so, individuals have to pay attention to their cognitive processes and understand how they can be trusted and what is the best way to handle them. Operatively, metacognitive competence should be developed by leading professionals to identify the mode of thinking -intuitive, heuristic or analytical -that is best suited to make the choices required by the clinical cases that they are facing. Suggestions concerning the way physicians working in emergency department can be trained to enhance their metacognitive skills are reported. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright A.
Problems for clinical judgement: 3. Thinking clearly in an emergency
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2001
The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Over-reliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into eff...
Understanding Decision-Making in Critical Care
Clinical medicine & research, 2015
Human decision-making in involves the deliberate formulation of hypotheses and plans as well as the use of subconscious means of judging probability, likely outcome, and proper action. There is a growing recognition that intuitive strategies such as use of heuristics and pattern recognition described in other industries are applicable to high-acuity environments in medicine. Despite the applicability of theories of cognition to the intensive care unit, a discussion of decision-making strategies is currently absent in the critical care literature. This article provides an overview of know cognitive strategies, as well as a synthesis of their use in critical care. By understanding the ways humans formulate diagnoses and make critical decisions, we may be able to minimize errors in our own judgments as well as build training activities around known strengths and limitations of cognition.
Academic Medicine, 2015
errors are a significant problem in medicine. In the emergency department (ED), the prevalence may as high as 20%. 1 Perhaps not surprisingly, then, much of the literature on diagnostic errors examines the ED. As Croskerry 2 explains: In this milieu, decision-making is often naked and raw, with its flaws highly visible. Nowhere in medicine is rationality more bounded by relatively poor access to information and with limited time to process it, all within a milieu renowned for its error-producing conditions. One characteristic feature of the ED is multiple interruptions, estimated at 10 to 20 per hour, which may increase errors. 3-5 Chisholm and colleagues 3 argue that to deal with disruptions, providers should employ cognitive forcing strategies, which are generalized techniques for increasing self-awareness: There is evidence supporting the negative effect of interruptions on task performance and subject perception of stress and … interruptions likely cause emergency medicine providers to compensate through task short cuts or failure to reengage in the task. This suggests that teaching cognitive forcing strategies to reorient after an interruption … may be beneficial to ED providers. 3(p121) Chisholm is one of a number of authors 6-8 who have argued that diagnostic errors arise from cognitive biases and can be reduced through explicit instruction on the nature of cognitive biases. Allied with the explicit identification of cognitive bias is the recommendation to slow down the decision-making process to allow more time for deliberation and reflection. Kahneman 9(p417) writes: The way to block errors that originate in System 1 is simple in principle: recognize the signs that you are in a conceptual minefield, slow down, and ask for reinforcement from System 2. [emphasis added] Please see the end of this article for information about the authors.
The Cognitive Imperative Thinking about How We Think
Academic Emergency Medicine, 2000
There are three domains of expertise required for consistently effective performance in emergency medicine (EM): procedural, affective, and cognitive. Most of the activity is performed in the cognitive domain. Studies in the cognitive sciences have focused on a number of common and predictable biases in the thinking process, many of which are relevant to the practice of EM. It is important to understand these biases and how they might influence clinical decision-making behavior. Among the specialities, EM provides a unique clinical milieu of inconstancy, uncertainty, variety, and complexity. Injury and illness are seen within narrow time windows, often under pressured ambient conditions. These operating characteristics force practitioners to adopt a distinctive blend of thinking strategies. Principal among them is the use of heuristics, a form of abbreviated thinking that often leads to successful outcomes but that occasionally may result in error. A number of opportunities exist to overcome interdisciplinary, linguistic, and other historical obstacles to develop a sound approach to understanding how we think in EM. This will lead to a better awareness of our cognitive processes, an improved capacity to teach effectively about cognitive strategies, and, ultimately, the minimization or avoidance of clinical error.