Balancing between EBM and a story that fits. The difference between routine and non-routine patients in medical diagnostics

Stéphanie Van Droogenbroeck

Onderzoeksoutput: Meeting abstract (Book)


Introduction Physicians are supposed to practice medicine that is based on the best available evidence. Evidence based medicine (EBM) –including randomized controlled trials (RCTs)- is therefore seen as the golden standard for good practice. But we know through the dual process theory that quick decisions are made differently than decisions for which we have more time, i.e. analytical vs. non-analytical thinking (Pelaccia et al. 2011). In a clinical setting physicians are supposed to help as many patients as possible in one day. The question rises how clinicians reason in such a time constraint setting? Is there a difference in the reasoning for routine patients and patients with more complex and even orphan diseases? Can we distinguish between the reasoning between expert physicians and non-experts in the case of complex and orphan diseases? What is the role for EBM during the reasoning in daily practice? Methods An ethnographic study in three hospitals (Belgium and USA) has been conducted. Patients with internal medical complaints at the emergency department, two wards and five departments at the outpatient clinic were included. The entire medical setting was observed, semi-structured interviews were taken from patients and their family. These data are analyzed with the grounded theory approach. Results and Discussion Physicians look in their knowledge base (combined of 1° scholarly/scientific or explicit knowledge, and 2° tacit or implicit knowledge (Polanyi 1958) that cannot be made explicit easily) for a similar case in the past as the case of the particular patient they need to diagnose this time. We call this “looking for a story that fits” or pattern recognition. Heuristics and biases also play a role in this process. This is the case when there is no skilled intuition available as a lack of satisfactory training and experience (Kahneman and Klein 2009). • Standard: Non-analytical thinking: • If skilled intuition is available: “Looking for a story that fits” • If not available: Use of heuristics with danger for biases • If fail: Analytical thinking: consulting (primary) literature (i.e. practicing EBM) and/or consulting a more experienced colleague. o This often happens in complex, non-routine and uncertain contexts. o Moreover, non-expert physicians tend to interpret routine cases as non-routine as a lack of expertise in that particular field of medicine. Therefore, non-experts use analytical reasoning in routine cases as they interpret them as “non-routine and complex”. o For experts and non-experts there is a preference for consulting a colleague instead of practicing EBM- especially for rare diseases. Conclusion Often non-analytical reasoning kicks in first during a diagnostic process. When this tactic fails, analytical thinking is used. For non-routine cases analytical thinking is often used to find the correct diagnosis. We must note that the interpretation of the context as complex or non-routine is different for expert and non-expert physicians. The role for EBM is minimal in the entire daily clinical practice for both groups of physicians. References Kahneman, D. and Klein, G. Conditions for intuitive expertise: a failure to disagree. American psychologist, 64, 2009: 515-526. Pelaccia, T., Tardif, J. Triby, E. and Charlin, B. An analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory. Medical education Online, 16, 2011: 5890-5898. Polanyi, M. Personal Knowledge. Towards a Post-Critical Philosophy. London: Routledge, 1962, 1974 <1958>.
Originele taal-2English
Titel2nd Conference ‘'Rare diseases not only in the curriculum'
StatusPublished - 26 mei 2015
Evenement2nd Conference Rare diseases not only in the curriculum - Szczecin, Poland
Duur: 26 mei 201530 mei 2015


Conference2nd Conference Rare diseases not only in the curriculum


Duik in de onderzoeksthema's van 'Balancing between EBM and a story that fits. The difference between routine and non-routine patients in medical diagnostics'. Samen vormen ze een unieke vingerafdruk.

Citeer dit