Decision analysis as a basis for medical decision making: the tree of hippocrates.
ABSTRACT Physicians have developed a number of implicit and explicit approaches to complex medical decisions. Decision analysis is an explicit, quantitative method of clinical decision making that involves the separation of the probabilities of events from their relative values, or utilities. Its use can help physicians make difficult choices in a manner that promotes true patient participation. Decision analysis also provides a framework for the incorporation of data from multiple sources and for the assessment of the impact of uncertain data on the final decision. Although this approach is imperfect, it represents a significant advance in clinical decision making.
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ABSTRACT: Recently, human reasoning, problem solving, and decision making have been viewed as products of two separate systems: "System 1," the unconscious, intuitive, or nonanalytic system, and "System 2," the conscious, analytic, or reflective system. This view has penetrated the medical education literature, yet the idea of two independent dichotomous cognitive systems is not entirely without problems.This article outlines the difficulties of this "two-system view" and presents an alternative, developed by K.R. Hammond and colleagues, called cognitive continuum theory (CCT). CCT is featured by three key assumptions. First, human reasoning, problem solving, and decision making can be arranged on a cognitive continuum, with pure intuition at one end, pure analysis at the other, and a large middle ground called "quasirationality." Second, the nature and requirements of the cognitive task, as perceived by the person performing the task, determine to a large extent whether a task will be approached more intuitively or more analytically. Third, for optimal task performance, this approach needs to match the cognitive properties and requirements of the task. Finally, the author makes a case that CCT is better able than a two-system view to describe medical problem solving and clinical reasoning and that it provides clear clues for how to organize training in clinical reasoning.Academic medicine: journal of the Association of American Medical Colleges 06/2013; · 2.34 Impact Factor
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ABSTRACT: the primary prevention of ischaemic stroke in chronic non-valvular atrial fibrillation (AF) typically involves consideration of aspirin or warfarin. CHA(2)DS(2)-VASc estimates annual stroke rates for untreated AF patients, which are reduced by 60% with warfarin and by 20% with aspirin. HAS-BLED estimates annual rates of major bleeding on warfarin. The latter risk with aspirin is 0.5-1.2% per year. given a 'warfarin, aspirin or no therapy' choice, AF patients will prefer the option that maximises the annual probability of not having a stroke and not having a major bleed. decision tree applied to the 60 possible combinations of CHA(2)DS(2)-VASc and HAS-BLED scores. according to the pre-specified hypothesis, when CHA(2)DS(2)-VASc is <2, the balance of risk and benefit would advise no treatment; when CHA(2)DS(2)-VASc is 2 or 3, warfarin would be best when HAS-BLED <2, otherwise no treatment would be advised; for CHA(2)DS(2)-VASc =4, warfarin would be best when HAS-BLED <3, otherwise no treatment would be advised and for CHA(2)DS(2)-VASc ≥5, warfarin would be the preferred option if HAS-BLED <4, otherwise aspirin would be advised. this theoretical exercise illustrates the potential benefit of decision analysis in an area where high complexity and uncertainty still remain.Age and Ageing 12/2011; 41(2):250-4. · 3.11 Impact Factor