Cause to Pause: A Purposeful Step towards Better Clinical Decision Making

Read on as Assoc Prof Raymond Goy, ADIO, KKH of SingHealth Residency and a clinician with more than 27 years of experience in healthcare, expounds the concept of clinical reasoning and decision making in healthcare through a series of True and False questions.

1.    We are trained to think critically in healthcare and we make sound clinical management decisions most of the time. True / False?

False. Even the most experienced clinicians can commit lapses in clinical reasoning and decision making, despite our best expertise and intentions. Cognitive errors are errors made by healthcare professionals despite possessing adequate knowledge and skill to make the right decisions. These errors are often due to subconscious influences and bias, especially during high stakes, high tension situations. It is now recognised that cognitive errors are one of the major contributory factors in medical errors.

2.    'Gut feeling' is always the cause of cognitive errors in healthcare. True / False?

False. Each of us possesses two distinct modes of thinking and reasoning (Croskerry & Nimmo, 2011):

• Intuitive reasoning, characterised by the 'gut reaction', is fast, impulsive, near effortless and may serve us well in certain situations in medicine. However, this type of reasoning is prone to errors.
  

•  Analytical reasoning is slow, deliberate, purposeful, and generally more reliable.

As the environment in the 'front line' can be volatile, ever changing and restricted by the lack of supply and time, our students and residents may be caught off-guard when challenging situations arise. To reduce the memory limitations and prevent excessive cognitive loading under these periods of stress and fatigue, one may subconsciously gravitate towards the reflexive intuitive mode of 'gut reaction'. This can potentially override the need for further analysis despite having prior knowledge and experience, resulting in an irrational act or cognitive errors.

3.    Cognitive errors in clinical situations can be prevented. True / False?

True. Cognitive errors are mistakes caused by our thought processes, influences and biases that hinder us from making the right decisions. Importantly, they can result in missed diagnoses, erroneous treatment and poorer patient outcomes. In overwhelmingly stressful clinical situations, these errors can occur in isolation or in combination, in high performing interprofessional teams.

To date, more than 20 forms of cognitive errors have been identified in medical specialties. The common ones include anchoring, availability bias, premature closure, confirmation bias and framing effect. Do actively recognise the existence of these errors in your practice through the resource provide below (Croskerry, 2003).

4.    Taking cognitive pauses will reduce medical errors. True / False?

True. While there are strategies we can implement at a systems level (i.e., team-based training, simulation training, use of protocols) to reduce the impact of these errors, the most pivotal tip is to groom your self-awareness.

• Taking cognitive pauses. Pausing for as short as a few minutes has been shown to improve clinical decision making, reduce imprecise reflexive responses and enhance performances. Taking a step back will also allow you to appreciate the broader perspective of the situations, provide opportunities for self-evaluation, for questions and for help seeking avenues.

• Consciously scan your work environment, and always reflect deliberately on your thoughts, emotions, predictions of your responses.

• Know your 'comfort zones' well. Be alert if you are veering from the established specialty norms into the areas of intuition and uncertainties in highly stressful situations.
  

5.    How else can we help our team mates to overcome stressful situations?

Always check in on your vulnerable fellow colleague – it could be someone who is new within your community of practice or someone who looks visibly stressed, tired or depressed. Share some of the tips that we have learnt today, and always extend your support to a colleague who could be taking a 'cognitive pause'.

References:

Croskerry, P. (2003). The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78(8), 775-780.

Croskerry, P., & Nimmo, G. (2011). Better Clinical Decision Making and reducing diagnostic error. The Journal of the Royal College of Physicians of Edinburgh, 41(2), 155-162.