A commentary on the use of evidence-based medicine as part of a more methodical approach to decision-making in clinical practice.
In a commentary written for the Journal of the American Veterinary Medical Association, Dr. Brennan McKenzie discusses the benefits and limitations inherent in the way we most often make clinical decisions and how we, as veterinarians, can use evidence-based medicine (EBM) as part of a more methodical approach to decision-making in clinical practice.
The author discusses a dominant model of decision-making theory called dual process theory, which classifies decision-making into either a system 1 or system 2 approach, and how we use these approaches in daily practice. For example, a system 1 approach involves making decisions based on experience or “intuition,” which takes less time, but is more prone to errors. System 2 is a more methodical approach to decision-making using things such as differential diagnosis lists, consultations, or diagnostic algorithms. Cognitive biases such as commission bias or making decisions based on habit can also affect the way we make clinical decisions and increases our risk of committing an error.
External constraints also influence decision-making. These external constraints, Dr. McKenzie explains, can range from the pressure of completing examinations within an allotted time period, to financial constraints placed on the veterinarian by the owner, to a lack of high-quality scientific data available with which to make an informed decision.
Dr. McKenzie points out that there is a need to incorporate cognitive psychology components and clinical reasoning skills into formal veterinary education in order to train veterinarians to not only strive for a system 2-based approach to decision-making, but also to acknowledge the limitations and biases. For example, consistent use of checklists as well as diagnostic and treatment algorithms has been shown to lower the risk of errors. These tools can be incorporated even within a busy practice setting and can help overcome barriers to using EBM techniques and system 2 decision-making processes.
Dr. McKenzie acknowledges that the constraints of time and money cannot be eliminated in the clinical practice setting, however, “the perfect should not be the enemy of the good.” Even if we cannot completely eliminate system 1 decision-making or always recognize and address our personal biases, there is room to improve—even small changes can make us better clinicians.
“Informed by an understanding of the errors we are prone to and the constraints imposed by the context of clinical practice, EBM can help us make better decisions and more effectively meet the needs of our patients and clients while reducing the stress of clinical practice,” concludes Dr. McKenzie.
McKenzie BA. Veterinary clinical decision-making: cognitive biases, external constraints, and strategies for improvement. J Am Vet Med Assoc 2014;244:271- 275.