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In this third and final blog post centred on the diagnostic process, we will explore the concepts discussed in the third paper published by Whitehead, Canfield, Johnson, O’Brien and Malik (2016) (https://doi.org/10.1177/1098612X16643251) around heuristics and illness scripts.
“Heuristics” can be defined as mental shortcuts and can act to support either System 1 or System 2 thinking.
There are many different kinds of heuristics, some of which can also be classed as biases (although when they are used as heuristics, they should give rise to correct diagnostic decisions more often than not!).
Names and descriptions of the different heuristics can be found in full in the paper inclusive of ‘availability’, ‘representativeness’, ‘familiarity’, relating to System 1 thinking and ‘anchoring and adjustment’, ‘means-end and hill-climbing and ‘progress-monitoring’, relating to System 2, heuristics.
But, for our purposes today we will just identify that these shortcuts are used often and effectively by skilled clinicians to respond efficiently to clinical conundrums.
Well sometimes, for example when you are on safari in Africa, using a heuristic that leads you to think that the hoofbeats belong to horses is going to be misleading. However, if you are aware of the heuristic/s that you are using and are able to deploy some reflection, you will surmise that in this case (as you are ambling along in an African savanna) zebras might indeed be a possibility that is worth considering.
As we gain experience, the knowledge that is stored in long-term memory is used to drive diagnoses through the use of heuristics.
To the untrained observer, this may appear as the senior clinician has regressed to simple pattern recognition (and is just lucky to get it correct!) but, for those excellent senior diagnosticians, it is actually quite a different process that is being employed. Prior cases, along with multiple alternate modes of learning and deep reflection, create a catalogue of long-term memories that are then able to be called upon quickly, through heuristics and partial or complete ‘illness scripts’, to work through initial presentations efficiently using System 1 thinking.
Note, that it is not a passive process that leads to this point! Vital here to the success of the senior clinician’s strategy (relating to the case at hand and also for coding of this information for future cases) is the subsequent use of effortful System 2 thinking, which may also be based on heuristics that drive general diagnostic strategies, along with other evidence-based strategies inclusive of diagnostic algorithms. The use of these techniques reinforces or refutes the progress made through the deployment of heuristics and scripts in System 1 thinking, by calling out and managing any cognitive error that has occurred.
If this sounds familiar, it is! We are talking about the same pattern that we discussed in the last post, but now with some deeper understanding of the mechanisms that drive the processes.
So, to end our series on diagnosis, we defer back to Kahneman’s central message, which is simply that when our minds are left to their own devices they engage in a number of erroneous ways of thinking. If we want to make better decisions, we need to be aware of these systematic errors and develop workarounds.
and
A deep dive into veterinary diagnosis: Part 1 Intuitive & Analytical Systems
A deep dive into veterinary diagnosis: Part 2 Managing Cognitive Error
This post first appeared on the AMR Vet Collective website on 19.4.2022
At The AMR Collective, we translate the science around AMR and stewardship into meaningful and practical information that veterinarians can call upon to make informed,evidence-based decisions in their daily practice.
At The AMR Collective, we translate the science around AMR and stewardship into meaningful and practical information that veterinarians can call upon to make informed, evidence-based decisions in their daily practice. We want every clinician to feel confident in understanding stewardship principles so that they can diagnose, prescribe, and manage infectious patients with confidence.
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