A Primer on Clinical Experience in Medicine: Reasoning, Decision Making, and Communication in Health Sciences PDF

Foreword

This is a timely book. Educators currently lament a lack of critical thinking at the secondary education level and in postsecondary education. This has translated into medical school entrants who are probably wanting in critical reasoning skills.

The issue was addressed in 2011 at the Harvard Millennium Conference on critical thinking. Teams from across North America met for two days to debate the issue. Pedagogical strategies were considered for the delivery of curricula to promote this fundamental skill at undergraduate, postgraduate, and continuing levels of medical education. The event was almost an anachronism; historically, medicine has probably done better in the past with respect to the underpinnings of thinking and reasoning. Philosophy, logic, and psychology were dominant in some of the earliest medical curricula. At the prestigious School of Medicine in Salerno, Italy, for example, in the Middle Ages, training these thinking skills took up a significant part of the undergraduate curriculum. In recent times, however, there has been a growing emphasis on declarative rather than procedural knowledge, that is, knowing that rather than knowing how. The electronic movement and manipulation of knowledge are far more disposed to declarative content than to informing us about how to think. Perhaps the Millennium Conference saw this coming and attempted to head it off.

In some ways, at this stage in the evolution of medical science, the notion of critical thinking and decision making (CTDM) might feel almost redundant. Surely, with the advent of increasingly sophisticated technology, the need for human cerebral input might become less rather than more. Take, for example, the case of a patient with undifferentiated abdominal pain: A detailed history and physical examination, coupled with laboratory and plain x-rays will yield a sensitivity of diagnosis in the order of about 30%, whereas a computed tomography (CT) scan delivers a sensitivity of over 90%. Why should clinicians even bother struggling with the formal process of collecting data, CTDM, establishing differential diagnoses, ordering and waiting for the results of laboratory tests (and dealing with their inherent error), and performing baseline imaging when at the push of a button they can triple their own performance? Novitiates to maritime navigation put forward a similar argument: Why should they learn the tedious principles of map reading, the use of a compass, and dead reckoning when they can simply press a button on a handheld global positioning system (GPS) navigation device?

Well, there are three issues to consider here: (1) The first is the cost and consequences of technology. Although GPS devices do emit microwave radiation, it is low and precautions can be taken to distance oneself from the device to reduce exposure. CT scanners, however, are a different matter, and there is growing concern about the amount of radiation to which patients are exposed. Too readily, we go for the effortless and quick answer neglecting to caution patients about their individual accumulating exposure. (2) The second is that technology may not always be available. The navigation device may fall overboard, and the CT scanner may break down or not be available. We will need backup in such circumstances, and, despite the shortcomings of the traditional routes, they do provide reasonable information that we can use. (3) The third, and perhaps the most important, is that we generally need to preserve our reasoning faculties. CT scanners and GPSs are of little value when it comes to making ethical decisions, choosing which politician to vote for, or agreeing with a partner on how best to raise children. The old saw "use it or lose it" applies here. The loss does not come in a Darwinian sense; instead, it arises from creeping cognitive indolence and the comfortable numbness of putting all our eggs in the basket of modern technology. There is a growing imperative to maintain the mental skills that we have painfully acquired over the last few thousand years and use them to maintain cerebral surveillance of the road ahead. Already, there are disquieting rumblings in medical corridors that as new generations of physicians come to rely more on managing information electronically, there has been an abandonment and loss of traditional skills. We should be concerned about this trend. Critical thinking needs preservation and promotion. It is the process by which we evaluate information and necessarily involves the exercise of good thinking habits so that sound reasoning occurs. Like any other skill, once acquired these habits need to be maintained.

In this book, Jenicek instructs us in the art of argumentation. This is not the widely used vernacular version such as having an argument with someone-often polarized with emotion and ending badly; instead, it is used as a vehicle of reasoning. Argumentation is "the act of forming reasons, making inductions, drawing conclusions, and applying them to the case in discussion; the operation of inferring propositions, not known or admitted as true, from facts or principles known, admitted, or proved to be true." It is said that reasoning, tested by argumentation, reflects doubt, and in a world where we are surrounded by uncertainty it would be as well if we understood the basic principles of argumentation; that is, claim, grounds, backing, warrant, qualifiers, and rebuttals. Jenicek illustrates how three distinct areas, medical reasoning, decision making, and multiple aspects of communication (including reading a medical article), can be systematically approached using the argumentation framework.

As he notes, modern medicine is characterized by incomplete information and uncertainty. The best we can usually do is to operate within a bounded rationality, making the best of what we have. We can, at least, impose a structure and discipline on our thinking, reasoning, and decision making that do not add to these shortcomings.

At the end of the day, asks Jenicek, can we afford not to be trained in logic, critical thinking and decision making? Two prominent demands on our thinking in medicine are (1) understanding the nature of the problem ( diagnosis) and (2) deciding what to do to fix it (treatment). The second won't work unless the first is correct. So, the emphasis in CTDM lies on getting the right diagnosis in a timely fashion. Our fallibilities in diagnosis mostly lie in faulty reasoning, not in knowledge deficits; critical thinking is mostly about overcoming cognitive bias.

There is burgeoning literature now on the two predominant forms of decision making: (1) intuitive and (2) rational. Two important books have contributed to our understanding: The first book, Thinking Fast and Slow (2011), by Nobel laureate Daniel Kahneman, has all but eliminated any residual conjecture about this as the ultimate framework for how we think. Kahneman painstakingly points to the numerous failures that occur in the intuitive mode, where most biases occur. The second book, Rationality and the Reflective Mind (2011), by Keith Stanovich, is a cutting-edge work on the psychological workings of the mind. An important feature of critical reasoning is that when the intuitive system goes looking for help in the analytical system, the latter must be up to it; this involves our reflective brain and how well it can reason. How well stocked is its toolbox for reasoning rationally and avoiding cognitive and affective biases, as well as logical fallacies? True reasoning, as Jenicek emphasizes, takes place only in the analytical mode of thinking. Argumentation is a conscious, deliberate, structured way of thinking that engages the reflective mind and decouples us from the pull of intuitive traps. Given that we spend probably 95% of our time in the intuitive mode, we need all the help we can get.

Canada's national media recently issued a challenge: "It's time for a Canadian renaissance in undergraduate education ... It ought to produce critical thinkers, scientifically and culturally literate people who can assess evidence, connect the dots and communicate with clarity-the key skills, that, in a fast-changing economy, prepare people for the jobs that haven't been invented yet" (Globe and Mail, October 10, 2011).

This book, A Primer on Clinical Experience in Medicine: Reasoning, Decision Making, and Communication in Health Sciences, is a primer on how physicians reason, but is also useful to practicing physicians and even teachers who have not undergone formal training in thinking. It is part of the renaissance. In his gentle and engaging way, with occasional humor thrown in, Jenicek takes the reader through the essentials.