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Dual Processing Model for Medical Decision Making

Case: 1 :

Chief Complaint: “Pain in Right Side” A 40-year-old man presents to his primary care provider (PCP) with right upper quadrant (RUQ) pain for 2 days. The pain is described as “sore” and rated 4 on 1 to 10 pain scale. The pain is intermittent and not worsening. He reports food does not seem to make it better or worse. No nausea or vomiting or diarrhea or constipation are reported.

Vital signs: heart rate, 75; blood pressure, 122/78; respiration rate, 15; afebrile.

Examination: No acute distress. Abdomen: mildly tender on palpation at RUQ; no masses, hepatomegaly or splenomegaly.

Diagnosis: Gallbladder disease.

Plan: Abdominal ultrasound with reflexive cholescintigraphy (hepatobiliary iminodiacetic acid) scan within 1 week. Patient instructed to call provider if worsening symptoms occur. He is also told to avoid any fatty foods or alcohol consumption. The patient is agreeable to plan.

Follow-up: Two days after the initial visit, the patient calls his PCP with worsening RUQ pain. Ultrasound imaging was scheduled for later that day. Patient then started having shortness of breath while at home and went to the local emergency department (ED). Computed tomography angiography of the chest revealed a right-sided pulmonary embolism. Patient did not have any family history of clotting disorders and no recent surgery, immobilization, or travel. Patient had been on testosterone injections for several years for low testosterone levels, and this was not updated in his medical record at his PC

Case 2

Chief Complaint: “Fever and Sleepy” A 3-year-old girl presents with her mother to a walk-in clinic with fever, nasal drainage, and fatigue for 2 days. She was observed hiding her head in her mother’s chest during the examination.

The presentation occurred during flu season. The clinician had 6 positive flu tests that day, all with similar symptoms, but most included a cough.

Vital signs: heart rate, 125; respiration rate, 20; blood pressure, 100/72; temperature, 100.8F.

Examination: Lungs clear, heart rate regular, no murmur. Head, eyes, ears, nose, and throat: normocephalic, conjunctivae clear, tympanic membrane without bulging or redness, pharynx normal, nares normal with clear drainage, tonsils 1þ, no erythema or exudate. The patient did not want to look at the clinician in a brightly lit room. The patient was lethargic and had limited tearing when crying. Rapid flu test: Negative.

Diagnosis: Presumptive seasonal influenza.

Plan: Supportive care, including encouraging fluids, Over-the-counter acetaminophen for fever, and age-appropriate antiviral medication for the flu was prescribed.

Follow-up: Parents were unable to keep her fever down over the next 1 day, and she progressively became more lethargic. The patient was taken to the ED, and a diagnosis of viral meningitis and dehydration was made. The patient spent several days in the hospital but did completely recover.

Describe the Dual Process Theory and Reasoning Process and how it applies to making decisions for the advanced practice nurse.
What are cognitive dispositions to respond? How are these applied in the APN setting?
Describe cognitive debiasing.
Describe how Type 1 (System 1) and Type 2 (System 2) processes and strategies can be applied to each case to help the NP make decisions and to decrease potential diagnostic errors.
What considerations for change to practice should the NP consider in each situation as a way to decrease the chance of future diagnostic and care decisions?

Full Answer Section

The reasoning process involves:

Problem Identification: Recognizing a clinical problem or issue.
Information Gathering: Collecting relevant information from the patient's history, physical examination, and laboratory tests.
Hypothesis Generation: Developing potential explanations for the problem.
Hypothesis Testing: Evaluating the plausibility of each hypothesis.
Decision Making: Selecting the most likely diagnosis and treatment plan.

2. Cognitive Dispositions to Respond

Cognitive dispositions to respond are mental frameworks that influence how we perceive and interpret information. In the APN setting, these dispositions can impact clinical decision-making:

Confirmation Bias: The tendency to seek information that confirms existing beliefs and ignore contradictory evidence.
Anchoring Bias: The tendency to rely too heavily on initial information, even if it is incomplete or inaccurate.
Availability Bias: The tendency to overestimate the likelihood of events that are easily recalled or vivid.
Hindsight Bias: The tendency to believe that past events were predictable, even when they were not.

3. Cognitive Debiasing

Cognitive debiasing involves techniques to reduce the impact of cognitive biases on decision-making. Some strategies include:

Critical Thinking: Actively questioning assumptions and seeking alternative perspectives.
Metacognition: Reflecting on one's own thinking processes to identify and correct biases.
Seeking Feedback: Obtaining input from colleagues or mentors to gain different perspectives.
Using Decision-Making Tools: Employing tools like checklists, algorithms, and decision trees to guide decision-making.

4. Applying System 1 and System 2 Thinking to the Cases

Case 1:

System 1: Quickly recognize the patient's presentation as a potential case of gallbladder disease based on the classic symptoms of RUQ pain.
System 2: Conduct a thorough history and physical exam, order appropriate diagnostic tests, and consider alternative diagnoses.

Case 2:

System 1: Recognize the child's lethargy and fever as potential signs of a serious infection.
System 2: Consider the differential diagnosis, including influenza, bacterial infection, and meningitis. Order appropriate laboratory tests and imaging studies to confirm the diagnosis.

5. Considerations for Change in Practice

Case 1:

Improve Documentation: Ensure that all relevant medical history, including testosterone therapy, is accurately documented in the electronic health record.
Enhance Diagnostic Accuracy: Consider using advanced imaging techniques, such as CT scans, to identify complications early.
Promote Patient Education: Educate patients about the importance of timely follow-up and the signs of worsening conditions.

Case 2:

Early Recognition of Serious Illness: Develop clinical guidelines for early identification of severe illness in children, particularly those with atypical presentations.
Improve Communication with Parents: Provide clear and concise information to parents about the child's condition and treatment plan.
Enhance Pediatric Assessment Skills: Continue to refine clinical skills in assessing pediatric patients, including the ability to recognize subtle signs of serious illness.

By understanding and applying these concepts, APNs can improve their decision-making skills, reduce diagnostic errors, and provide optimal care for their patients.

Sample Answer

1. Dual Process Theory and Reasoning Process

Dual Process Theory posits that human cognition involves two systems:

System 1: Fast, intuitive, and emotional thinking.
System 2: Slow, deliberate, and logical thinking.

In the context of decision-making for an Advanced Practice Nurse (APN), both systems play a crucial role. System 1 helps in rapid decision-making, especially in urgent situations, while System 2 is essential for complex problem-solving and critical thinking.