Transcript Clinical Decision Making

The Art Of Medicine
S.H. Ojaghi Haghighi MD
Case 1
A
64 years old man came to ED with
complaint of chest pain. He said:
 “I
have chest & back pain that awakened
me from sleep, it is severest pain that I
ever had, and I feel it stabbing my
chest.”
 He
has PMH of HTN & HLP.
Case 2
A
28 years old man came to ED with
complaint of chest pain. He said:
 “I
have chest pain from 2 days ago, it
was mild first but it’s more severe now,
it’s hard to breath, but when I sit, I feel
more better.”
 He
has no significant PMH. He mentioned
about catching cold 3 weeks ago.
Perspective
Physicians must be skilled efficiently in:

gathering data

use strategies
That:
promote maximal diagnostic proficiency
while limiting costs.
 Emergency
physicians:
– most facile and rapid decision makers in
medicine
What Decisions?
 Diagnosing
problem
and managing a patient's
 Managing
the staff,
 Managing
clinical environment
 Educational
responsibilities
Corner stones for accurate
diagnosis & management:
 Adequate
knowledge base of medical
information
 Decision-making
skills
What’s The Clinical Reasoning?
 Scientific
medicine
method of clinical
 Involves:
– Medical inquiry
– Clinical decision making
Medical Inquiry
 Gathering
medical data:
– History taking
– Ph Ex
– Diagnostic testing
 With
cognitive and psychomotor skills
Clinical Decision Making
 It’s
a cognitive process
 Utilize
the medical data to:
– Evaluate
– Diagnose
– Manage
Medical problems
If You Want to Approach to
Your Patient Properly
 The
first step is:
– Making a problem representation
 Problem
representation
or Illness script:
– Expressing your subjective & objective
finding by medical language
– links the patient's case to an existing
knowledge structure
If You Want to Approach to
Your Patient Properly
 The
second step is:
– Memorization of Illness fact or concept

A fact or concept:
– A group of objects, symbols, or events
with common characteristics referred to
by a collective name (acidosis, MI)
If You Want to Approach to
Your Patient Properly
 The
third step is:
– Applying one of the strategies
Strategies of Clinical Decision Making
 Pattern
recognition
 “Rule-using"
 Naturalistic
algorithm
or event driven
 Hypothetico-deductive
Pattern Recognition

the key is:
– Making relation between scripts & facts
– That’s it, you have disease pattern
 More
experienced, more pattern
recognition

So Experienced physicians can use pattern
recognition or the "doorway diagnosis“ more
readily
Pattern Recognition
 Content
of disease pattern:
– Little knowledge about pathology or
physiology
– Associated signs and symptoms
– Consequences
– Clinically relevant information
 Pattern
recognition is:
– Automatic
– Operates briefly
– Processes information rapidly
 Lowest
level of the clinical decision
making hierarchy
Rule-Using Process
 Algorithms
and clinical pathways.
 Recognition
of the pattern:
– Pre-requisite to applying the correct rule

Use previously memorized rules of the
"if X then Y"
When Do You Use Rules?

You can use it:
– Atypical presentations
– Unusual symptom complexes
– Critical or high stress situation


Such as algorithms for ACLS or Altered Mental
Status
It can be minimizing the chance for human
error
Naturalistic, or Event-Driven,
Process




Treat patients' signs or symptoms before definitive
diagnoses
Stabilizing an unstable patient before knowing the
exact cause of instability
Utilized in emergency medicine than any other
specialty
Switch from evaluation of diagnostic possibilities
evaluation of possible therapeutic trials.
to
Naturalistic, or Event-Driven,
Process

Ruling out the worst-case scenario

Focus on stabilizing actions and not diagnoses
Rapidly prune the decision tree

Accept a good or likely presumptive diagnosis
instead of the definitive diagnosis
Hypothetico-Deductive Process


Highest in the clinical decision-making
hierarchy
Knowledge based:
– Intellectual ability
– Problem solving using previous knowledge

It requires conscious, analytic processing of
stored knowledge
Hypothetico-Deductive Process
Hypothesis generation:
Initial cues from history & Ph.Ex & environment
=> multiple diagnostic hypotheses.
 Hypothesis evaluation:
The cues and data are interpreted to confirm or
reject the provisional hypotheses.
 Hypothesis refinement:
A process that may lead to additional
diagnostic hypotheses being generated.
 Hypothesis verification:
Finally, the physician chooses and verifies the
most likely diagnosis (confirmed by data).

Which Clinical Decision-Making
Process Is Best?
 It
depends on:
– Experience of the clinician
– Difficulty or uniqueness of the medical
problem
Inexperienced physicians:
 Exhaustive
Ph.ex
in their history taking and
 Inability
to discern sufficient cues to
develop a DDx
 Unfocused
diagnostic tests
 Undeveloped
association of presenting
signs, symptoms, and diagnostic study
Experienced physicians:
 Facing
with a complex patient who
does not "fit" into their memorized
disease patterns:
– Details of history, Ph.Ex, diagnostic tests,
or therapeutic trials
– Assess the possibility of significant or
life-threatening disease
Which is best?

Inexperienced physicians:
– Highest level of diagnostic decision making
(hypothetico-deductive) early in their career

More experience:
– Pattern recognition (gradually)
– Forgetting details if consistently used

Facing with critical, atypical presentation:
– Decision-making algorithms and clinical pathways
– Less mental effort
What can we do?

Sit at patient's bedside to collect a thorough
history

Perform an uninterrupted physical examination

Generate life-threatening and most likely
diagnostic hypotheses

Use information databases and expert systems to
broaden diagnostic hypotheses



Collect data to confirm or exclude life threats
first, then most likely diagnoses
Avoid diagnostic testing whenever possible by
using available decision making algorithms
(e.g., Ottawa ankle rules)
Use guidelines and protocols for specific
therapeutic decisions to conserve mental
energies
What can we do?

Allow 2 to 3 minutes of uninterrupted time to
mentally process each patient

Mentally process one patient at a time to
disposition

Avoid decision making when overly stressed or
angry:
– Take 1 to 2 minutes out, regroup, then make the
decision
What can we do?


Carry a maximum of 4 or 5 "undecided"
category patients
Stop-make some dispositions
Use evidence-based medicine techniques
Medicine is not only a
science but an art