Skip to main content

Clinical Decision Making

  • Chapter
  • First Online:
Pediatric and Congenital Cardiac Care

Abstract

In every domain of medicine, decisions are continuously being made about patients’ diagnosis and management. Arguably, decision making is the most important aspect of a patient’s care and the most likely to affect their safety, yet physicians generally do not receive comprehensive training in this basic skill. In this chapter, dual process theory, the dominant model of clinical decision making, is reviewed. The two basic modes of decision making are intuitive and analytical. The properties of the two systems are discussed, as is their dynamic relationship with each other in the operating characteristics of the model.

Many of the requirements for improving decision making can be found in the burgeoning literature on critical thinking. Significant gains in decision making skills can be made by teaching the basics of decision making within a critical-thinking framework and by thoroughly understanding the nature and extent of cognitive and affective biases and how to mitigate them. There remains an overarching need for research in clinical decision making that is relevant to the clinical settings and conditions under which decisions are made.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 179.00
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Rao G. Rational medical decision making: a case based approach. New York: McGraw-Hill Medical; 2007.

    Google Scholar 

  2. Lakoff G, Johnson M. Philosophy in the flesh: the embodied mind and its challenge to western thought. New York: Basic Books; 1999.

    Google Scholar 

  3. Croskerry P. From mindless to mindful practice: cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445–8.

    Article  CAS  PubMed  Google Scholar 

  4. American Psychological Association. Glossary of psychological terms. From: http://www.apa.org/research/action/glossary.aspx. Retrieved 30 May 2013.

  5. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009;14:27–35.

    Article  PubMed  Google Scholar 

  6. Lieberman MD, Jarcho JM, Satpute AB. Evidence-based and intuition-based self-knowledge: an FMRI study. J Pers Soc Psychol. 2004;87(4):421–35.

    Article  PubMed  Google Scholar 

  7. Schneider W, Shiffrin RM. Controlled and automatic human information processing: 1. Detection, search, and attention. Psychol Rev. 1977;84:1–66.

    Article  Google Scholar 

  8. Dawson NV. Physician judgment in clinical settings: methodological influences and cognitive performance. Clin Chem. 1993;39:1468–80.

    CAS  PubMed  Google Scholar 

  9. Croskerry P. A universal model for diagnostic reasoning. Acad Med. 2009;84:1022–8.

    Article  PubMed  Google Scholar 

  10. Stanovich KE. The robot’s rebellion: finding meaning in the age of Darwin. Chicago: The University of Chicago Press; 2004.

    Book  Google Scholar 

  11. Campbell WW. Augenblickdiagnose. Semin Neurol. 1998;18:169–76.

    Article  CAS  PubMed  Google Scholar 

  12. Silen W. Cope’s early diagnosis of the acute abdomen. 15th ed. New York: Oxford University Press; 1979.

    Google Scholar 

  13. Smallberg G. Bias is the nose for the story. In: Brockman J, editor. This will make you smarter. New York: Harper Perennial; 2012. p. 43–5.

    Google Scholar 

  14. Kahneman D. Thinking, fast and slow. 7th ed. Toronto: Doubleday Canada; 2011.

    Google Scholar 

  15. Denes-Raj V, Epstein S. Conflict between intuitive and rational processing: when people behave against their better judgment. J Pers Soc Psychol. 1994;66:819–29.

    Article  CAS  PubMed  Google Scholar 

  16. Hogarth RM. Educating intuition. Chicago: The University of Chicago Press; 2001.

    Google Scholar 

  17. Stanovich KE. Dysrationalia: a new specific learning disability. J Learn Disabil. 1993;26:501–15.

    Article  CAS  PubMed  Google Scholar 

  18. Rorty AO. Self-deception, akrasia and irrationality. In: Elster J, editor. The multiple self. Cambridge: Cambridge University Press; 1985. p. 115–31.

    Google Scholar 

  19. Kalis A, Mojzisch A, Schweizer TS, Kaiser S. Weakness of will, akrasia, and the neuropsychiatry of decision making: an interdisciplinary perspective. Cogn Affect Behav Neurosci. 2008;8:402–17.

    Article  PubMed  Google Scholar 

  20. Stroud S, Tappolet C. Weakness of will and practical irrationality. New York: Oxford University Press; 2008.

    Google Scholar 

  21. Hammond KR. Intuitive and analytic cognition: information models. In: Sage A, editor. Concise encyclopedia of information processing in systems and organizations. Oxford: Pergamon Press; 1990. p. 306–12.

    Google Scholar 

  22. Critical Thinking Community. Our concept and definition of critical thinking. From: http://www.criticalthinking.org/pages/our-concept-of-critical-thinking/411. Accessed 20 May 2013.

  23. Croskerry P. ED cognition: any decision by anyone at any time. ED administration series. CJEM. 2014;16(1):13–9.

    PubMed  Google Scholar 

  24. Croskerry P, Musson D. Individual factors in patient safety. In: Croskerry P, Cosby KS, Schenkel S, Wears R, editors. Patient safety in emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 269–76.

    Google Scholar 

  25. Croskerry P. Context is everything or how could I have been that stupid? Healthc Q. 2009;12(Suppl):e171–s1763. doi:10.12927/hcq.2009.20945.

    Article  PubMed  Google Scholar 

  26. Croskerry P. The importance of cognitive errors in diagnosis and strategies to prevent them. Acad Med. 2003;78:1–6.

    Article  Google Scholar 

  27. Croskerry P. Cognitive and affective dispositions to respond. In: Croskerry P, Cosby KS, Schenkel S, Wears R, editors. Patient safety in emergency medicine. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 219–27.

    Google Scholar 

  28. Jenicek M. Medical error and harm: understanding, prevention and control. New York: Productivity Press, Taylor and Francis Group; 2011.

    Google Scholar 

  29. Wikipedia, the Free Encyclopedia. List of cognitive biases. From: http://en.wikipedia.org/wiki/List_of_cognitive_biases. Accessed 31 May 2013.

  30. Dobelli R. The art of thinking clearly. New York: HarperCollins; 2013.

    Google Scholar 

  31. The Critical Thinking Community: Critical Thinking: Where to Begin. From: http://www.criticalthinking.org/pages/critical-thinking-where-to-begin/796. Accessed 1 May 2013.

  32. Croskerry P. Bias: a normal operating characteristic of the diagnosing brain. Diagnosis. 2014;1:23–7.

    Article  Google Scholar 

  33. Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology. Br J Anaesth. 2012;108:229–35.

    Article  CAS  PubMed  Google Scholar 

  34. David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, Craft N. Diagnostic accuracy in patients admitted to hospital with cellulitis. Dermatol Online J. 2011;17:1.

    PubMed  Google Scholar 

  35. Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9:1184–204.

    Article  PubMed  Google Scholar 

  36. Hershberger PJ, Markert RJ, Part HM, Cohen SM, Finger WW. Understanding and addressing cognitive bias in medical education. Adv Health Sci Educ Theory Pract. 1997;1:221–6.

    Article  Google Scholar 

  37. Vickrey BG, Samuels MA, Ropper AH. How neurologists think: a cognitive psychology perspective on missed diagnoses. Ann Neurol. 2010;67(4):425–33.

    Article  PubMed  Google Scholar 

  38. Dunphy BC, Cantwell R, Bourke S, Fleming M, Smith B, Joseph KS, Dunphy SL. Cognitive elements in clinical decision-making. Toward a cognitive model for medical education and understanding clinical reasoning. Adv Health Sci Educ Theory Pract. 2010;15:229–50.

    Article  PubMed  Google Scholar 

  39. Margo CE. A pilot study in ophthalmology of inter-rater reliability in classifying diagnostic errors: an under investigated area of medical error. Qual Saf Health Care. 2003;12:416–20.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Foucar E. Error in anatomic pathology. Am J Clin Pathol. 2001;116:S34–46.

    Article  PubMed  Google Scholar 

  41. Crowley RS, Legowski E, Medvedeva O, Reitmeyer K, Tseytlin E, Castine M, Jukic D, Mello-Thoms C. Automated detection of heuristics and biases among pathologists in a computer-based system. Adv Health Sci Educ Theory Pract. 2013;18(3):343–63. doi:10.1007/s10459-012-9374-z. Published online: 23 May 2012.

    Article  PubMed Central  PubMed  Google Scholar 

  42. Singh H, Thomas EJ, Wilson L, Kelly PA, Pietz K, Elkeeb D, Singhal G. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126:70–9.

    Article  PubMed Central  PubMed  Google Scholar 

  43. Crumlish N, Kelly BD. How psychiatrists think. Adv Psychiatr Treat. 2009;15:72–9.

    Article  Google Scholar 

  44. Sabih D, Sabih A, Sabih Q, Khan AN. Image perception and interpretation of abnormalities; can we believe our eyes? Can we do something about it? Insights Imaging. 2011;2:47–55.

    Article  PubMed Central  PubMed  Google Scholar 

  45. Shiralkar U. Smart surgeons, sharp decisions: cognitive skills to avoid errors and achieve results. Shropshire: TFM Publishing; 2010.

    Google Scholar 

  46. Gillon SA, Radford ST. Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. Crit Care Resusc. 2012;14:216–21.

    PubMed  Google Scholar 

  47. Hicks EP, Kluemper GT. Heuristic reasoning and cognitive biases: are they hindrances to judgments and decision making in orthodontics? Am J Orthod Dentofacial Orthop. 2011;139:297–304.

    Article  PubMed  Google Scholar 

  48. Fischoff B. Debiasing. In: Kahneman D, Slovic P, Tversky A, editors. Judgment under uncertainty; heuristics and biases. Cambridge: Cambridge University Press; 1982. p. 422–44.

    Chapter  Google Scholar 

  49. Kahneman D, Slovic P, Tversky A, editors. Judgment under uncertainty; heuristics and biases. Cambridge: Cambridge University Press; 1982.

    Google Scholar 

  50. Plous S. The psychology of judgment and decision making. New York: McGraw-Hill; 1993.

    Google Scholar 

  51. Baron J. Thinking and deciding. 3rd ed. New York: Cambridge University Press; 2000.

    Google Scholar 

  52. Gilovich T, Griffin D, Kahneman D. Heuristics and biases: the psychology of intuitive judgment. New York: Cambridge University Press; 2002.

    Book  Google Scholar 

  53. Bishop MA, Trout JD. Epistemology and the psychology of human judgment. New York: Oxford University Press; 2005.

    Book  Google Scholar 

  54. Vohs KD, Baumeister RE, Loewenstein G. Do emotions help or hurt decision making? A hedgefoxian perspective. New York: Russell Sage; 2007.

    Google Scholar 

  55. Damasio A. Self comes to mind: constructing the conscious brain. New York: Pantheon Books; 2010.

    Google Scholar 

  56. Konnikova M. Mastermind: how to think like Sherlock Holmes. New York: Viking; 2013.

    Google Scholar 

  57. Markman A. Smart thinking; three essential keys to solve problems, innovate, and get things done. New York: Perigree; 2012.

    Google Scholar 

  58. Chabris C, Simons D. The invisible gorilla. New York: Crown; 2010.

    Google Scholar 

  59. Lehrer J. How we decide. New York: Houghton Mifflin Harcourt; 2009.

    Google Scholar 

  60. Hallinan JT. Why we make mistakes: how we look without seeing, forget things in seconds, and are all pretty sure we are way above average. New York: Broadway Books; 2009.

    Google Scholar 

  61. Thaler RH, Sunstein CR. Nudge: improving decisions about health, wealth, and happiness. New York: Penguin; 2008.

    Google Scholar 

  62. Brafman O, Brafman R. Sway: the irresistible pull of irrational behavior. New York: Broadway Books; 2008.

    Google Scholar 

  63. Ariely D. Predictably irrational: the hidden forces that shape our decisions. New York: HarperCollins; 2008.

    Google Scholar 

  64. Wolpert L. Six impossible things before breakfast: the evolutionary origins of belief. New York: W.W. Norton; 2007.

    Google Scholar 

  65. Tavris C, Aronson E. Mistakes were made (but not by me): why we justify foolish beliefs, bad decisions and hurtful acts. Orlando: Harcourt Inc.; 2007.

    Google Scholar 

  66. Myers DG. Intuition: its powers and perils. New Haven: Yale University Press; 2002.

    Google Scholar 

  67. Piattelli-Palmarini M. Inevitable illusions: how mistakes of reason rule our minds. New York: Wiley; 1994.

    Google Scholar 

  68. Stanovich KE. Rationality and the reflective mind. New York: Oxford University Press; 2011.

    Google Scholar 

  69. Graber ML, Kissam S, Payne VL, Meyer D, Sorensen A, Lenfestey N, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21:535–57.

    Article  PubMed  Google Scholar 

  70. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121(5, Suppl 1):S2–23.

    Article  PubMed  Google Scholar 

  71. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of de-biasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58–64.

    PubMed  Google Scholar 

  72. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf. 2013;22 Suppl 2:ii65–72.

    PubMed  Google Scholar 

  73. Eichhorn R. Developing thinking skills: critical thinking at the army management staff college. Strategic Systems Department Army Management Staff College. 2013. From: http://www.au.af.mil/au/awc/awcgate/army/critical/roy.htm. Accessed 15 May 2013.

  74. Miller DR. Longitudinal assessment of critical thinking in pharmacy students. Am J Pharm Educ. 2003;67:1–8.

    Article  Google Scholar 

  75. Solon T. Generic critical thinking infusion and course content learning in introductory psychology. J Instr Psychol. 2007;34:95–109.

    Google Scholar 

  76. Twardy CR. Argument maps improve critical thinking. Teach Philos. 2004;27:2.

    Google Scholar 

  77. Butler HA, Dwyer CP, Hogan MJ, Franco A, Riva SF, Saiz C, Almeida LS. The halpern critical thinking assessment and real-world outcomes: cross-national applications. Thinking Skills Creativity. 2012;7:112–21.

    Article  Google Scholar 

  78. Higgins S, Hall E, Baumfield V, Moseley D. A meta-analysis of the impact of the implementation of thinking skills approaches on pupils. In: Research evidence in education library. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London; 2005. From: http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=338. Accessed 30 May 2013.

  79. Friend CM, Zubek JP. The effects of age on critical thinking ability. J Gerontol. 1958;13:407–13.

    Article  CAS  PubMed  Google Scholar 

  80. Denney NW. Critical thinking during the adult years: has the developmental function changed over the last four decades? Exp Aging Res. 1995;21:191–207.

    Article  CAS  PubMed  Google Scholar 

  81. Croskerry P, Petrie D, Reilly J, Tait G. Deciding about fast and slow decisions. Acad Med. 2014;2:197–200.

    Article  Google Scholar 

  82. Fang FC, Casadevall A. Reductionistic and holistic science. Infect Immun. 2011;79:1401–4.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  83. Stark M, Fins JJ. The ethical imperative to think about thinking. Cambridge Quarterly of Healthcare Ethics. 2014;23:386–96.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Pat Croskerry MD, PhD, FRCP (Edin) .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer-Verlag London

About this chapter

Cite this chapter

Croskerry, P. (2015). Clinical Decision Making. In: Barach, P., Jacobs, J., Lipshultz, S., Laussen, P. (eds) Pediatric and Congenital Cardiac Care. Springer, London. https://doi.org/10.1007/978-1-4471-6566-8_33

Download citation

  • DOI: https://doi.org/10.1007/978-1-4471-6566-8_33

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-6565-1

  • Online ISBN: 978-1-4471-6566-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics