We are going to be talking about

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1 Measuring Clinical Decision-Making Paula O Neill, MEd, EdD Muhammad Walji, PhD The University of Texas Dental Branch at Houston We are going to be talking about Types of decisions made in clinical dental education Approaches of decisionmaking Strategies for measuring clinical decisions Muhammad.F.Walji@uth.tmc.edu) 1 2

2 Format of workshop Interactive Questions and comments always welcome Who is here? Personal objectives? 3 Patient case 57 yr old male Gino Deep New patient Chief compliant loose Red gums Unremarkable med hx Claims no smoking Moderate drinker Elevated cholesterol Meds Crestor 325 mg of unbuffered aspirin Dental exam Poor oral health Stained teeth loose Bleeding upon probing In general Smells like a smoker Muhammad.F.Walji@uth.tmc.edu) 2 4

3 Clinical decision-making in dental education In small groups, come to a consensus on How to define clinical-decisionmaking in dental education Large group discussion 5 From: A practical guide to clinical medicine. Charlie Goldberg, MD, UCSD Process by which we determine Who needs what and when Muhammad.F.Walji@uth.tmc.edu) 3 6

4 Faculty general discussion What common clinical decisions do you make as a faculty member? How do you evaluate those decisions? 7 Students -- general discussion What common clinical decisions do students make? In your dental school, in general how do faculty evaluate processes used or decisions made by students? Muhammad.F.Walji@uth.tmc.edu) 4 8

5 Clinical decision-making: Patients/family PEW Internet and American Life Project 2006 Many patients and families want to be involved in clinical decision-making 113,000,000 consumers search for health information on the Internet 15% search for dental Patient types Passive Collaborative Active How do you evaluate your patient s type? How do you measure patient s ability to evaluate health information From Stiggelbout Patients/family general decisions What healthcare decisions do dental patients and family members make? How do you assist students in helping their patients make decisions? What role does faculty expertise play in this process? Muhammad.F.Walji@uth.tmc.edu) 5 10

6 Decision-Making Novice versus Experts Novice (Student) Inflexible (rule-bound and dogmatic) Slow, hesitant, lacks confidence Cannot access needed knowledge quickly Emotions take-over (seek stress-reducing action) Focus address surface features of problem Flawed thinking: premature closure, anchoring, faulty synthesis, ignore key data Experts (Faculty) Adapt to circumstances (flexible) Fast, fluid, confident Remain calm; don t act until necessary Focus address source of problem Avoid snap judgments; willing to change mind; focus on key details 11 Paternalistic Eysenbach G., Jadad AR. J Med Internet Res 2001;3(2):e19 Muhammad.F.Walji@uth.tmc.edu) 6 12

7 Educational Eysenbach G., Jadad AR. J Med Internet Res 2001;3(2):e19 13 Internet-age Eysenbach G., Jadad AR. J Med Internet Res 2001;3(2):e19 Muhammad.F.Walji@uth.tmc.edu) 7 14

8 Consumer-as partner Eysenbach G., Jadad AR. J Med Internet Res 2001;3(2):e19 15 Having an experience with decisionmaking Diagram the decisionmaking process you would undertake to BUY a home Either a condo in a highrise with great view Versus a ranch home with a large backyard and swimming pool Muhammad.F.Walji@uth.tmc.edu) 8 16

9 Two approaches to decision-making Describe a rational approach to buying a house Describe a heuristic approach to buying a house How do you measure your effectiveness at decision-making? 17 Heuristic systematic processing approach Chaiken I want to buy jewelry What decisions need to go into whether I buy or not Systematic approach Rational decision-making Heuristic approach Rules of thumb Any potential biases? Muhammad.F.Walji@uth.tmc.edu) 9 18

10 Clinical-decision-making approaches cont. Donald Woolever Patterns Scientific method Probabilities Differential diagnosis Treatment thresholds Context Shared decisionmaking 19 Patterns differences between novices and experts Trained to recognize patterns Examples 28 yo F with new onset of chest pain when in dental chair 65 yo M with new onset of chest pain first noticed by 4 th yr student What patterns (clinical decisions) might we focus upon with either of these patients? Flawed decisionmaking? Muhammad.F.Walji@uth.tmc.edu) 10 20

11 Scientific method Each patient encounter is a mini research project Problem ID Develop hypothesis Collect/analyze data Confirm/deny hypothesis 37 yr M presents with Fever of unknown origin Diffuse pain in lower left jaw No obvious redness or swelling Based upon scientific method what is your clinical decision-making process with only these facts? 21 Probabilities Establish likelihood of given outcome How does this happen in dental education? Helpful in selecting and interpreting right tests Ordering shotgun tests with very lowpretest probabilities usually results in wasted time and energy Muhammad.F.Walji@uth.tmc.edu) 11 22

12 Differential diagnoses Differential lists are either too broad or limited Focus on worst diagnosis Probable cancer Pragmatic only focusing on the diagnosis that We can do something about it today Makes us feel better to come up with treatment plan at initial visit 23 Treatment thresholds Have to make complicated decisions Thresholds that have to be crossed before moving forward in clinical decisionmaking Low threshold Treatment has marked benefit and low risk for patient Annual cleaning Higher threshold Only limited benefit for those with the problem and moderate for those without problem wisdom tooth extraction 12 24

13 Context Patient s context Clinician s context Provider must consider context How would the patient s context affect your clinical decisionmaking? How would YOUR context affect your clinical decisionmaking? 25 Shared decision-making Best decisions often made in partnership with our patients Clinician has expertise Patient has prior knowledge about his or her condition, risk tolerance, values, preferences Muhammad.F.Walji@uth.tmc.edu) 13 26

14 Measuring clinical decision-making What approaches do you use to measure clinical decisionmaking Each table discusses one of the following Self as a faculty member Student Patient/family 27 Commonly used Structured essays Structured Essays Domain Type of Use Limitations Strengths Written by students Criterionbased Synthesis of information, interpretation of dental or medical literature Preclinical courses Time consuming to grade Calibration is a must for interrater reliability Avoids cueing, uses higher-order cognitive processes Long testing time required to encompass variety of domains Muhammad.F.Walji@uth.tmc.edu) 14 28

15 Evaluations by Supervising Clinicians Method Domain Type of use Limitations Strengths Global ratings with comments Structured direct observations using checklists Oral examinations Clinical skills, communication Communication skills, clinical skills Knowledge, clinical reasoning Sometimes formative but generally summative Limited use Limited use in clinical settings Based upon 2 nd hand reports and case presentations Selective rather than habitually observed behaviors Subjective, sex and race bias reported To overcome variability due to subjectivity, use multiple independent raters Feedback by credible experts Feedback from credible experts 29 Commonly used Clinical Simulations Method Domain Type of use Limitations Strengths Standardized patients & objective structured clinical examinations (OSCE s) Standardized patients Technology simulations Some clinical skills; interpersonal behaviors; communication Actual practice habits Procedural skills, teamwork, simulated clinical cases Formative & summative assessments Often used in research; formative feedback Formative and summative measurement Timing & setting seem artificial, requires suspension of disbeliefs Requires prior consent, challenging logistically Timing & setting may seem artificial; expensive Tailored to educational goals; reliable, consistent case presentation & ratings Very realistic; most accurate way of measuring Tailored to educational goals; observed by faculty 30 Muhammad.F.Walji@uth.tmc.edu) 15

16 Experiences in measuring clinicaldecision-making using cases 31 Pitfalls of clinical decision-making Woolever Satisfaction of the search Fall back on lower level decision making rules to eliminate alternatives Diagnosis momentum Tendency to ignore findings that lead us in different directions than the one in which we are already headed Commission bias Tendency to do something rather than watchful waiting Intuitive leaps Tendency to make a jump to a diagnosis that is not supported by evidence or logic GUT INSTINCT Muhammad.F.Walji@uth.tmc.edu) 16 32

17 Other issues related to evaluating clinical decision-making Have you established standards or calibration to determine level of competency? To what extent do the students demonstrate the expected level of performance? Do your faculty agree upon these standards? Are the standards communicated to the students? Is there deviation from the expected competency or standard that you are willing to accept? 33 Wrapping up Summary of measurement approaches Comments Questions Unanswered objectives? 17 34

18 References Chaiken S, Trope Y. Dual process/theories and social psychology NY: Guilford Press. Denig P, Haaijer-Ruskamp FM. Thinking aloud as a method of analysing the treatment decisions of physicians. European J of Pub Health (1): Epstein RM. Assessment in medical education. In Cox M, Irby DM, (Eds). NEJM (4): Fox S. Pew Internet and American Life Project Online Health Search Accessed Goldberg C. A practical guide to clinical medicine. University of California San Diego. Accessed References cont. Groopman J. How doctors think Boston: Houghton Mifflin. Johnson BR, Schwartz A, Goldberg J. Koerber A. A chairside aid for shared decision making in dentistry: A randomized controlled trial. J Dent Educ (2): Norcini J. Back to the future: Clinical vignettes and the measurement of physician performance. Annuals of Internal Medicine (10): Peabody JW, Luck F, Glassman P, Dresselhaus TR. Comparisons of vignettes, Standardized patients and chart abstraction. JAMA. 2000;283: Muhammad.F.Walji@uth.tmc.edu) 18 36

19 References Sox HC, Blatt MA, Higgins MC, Marton KI. Medical Decision Making Philadelphia: American College of Physicians. Stiggelbout A, Kiebert G. A role for the sick role. Can Med Assoc (4): Vertinsky IB, Thompson WA. Uyeno D. Measuring consumer desire for participation in clinical decisionmaking. Health Services Research. Summer pp Woolever DR. The art and science of clinical decisionmaking. May Family Practice Management. Accessed nals/fpm.html 37 Muhammad.F.Walji@uth.tmc.edu) 19