A Primer on Clinical Experience in Medicine : Reasoning, Decision Making, and Communication in Health Sciences book cover
1st Edition

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

ISBN 9781466515581
Published August 8, 2012 by CRC Press
368 Pages 20 B/W Illustrations

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Book Description

Mastery of quality health care and patient safety begins as soon as we open the hospital doors for the first time and start acquiring practical experience. The acquisition of such experience includes much more than the development of sensorimotor skills and basic knowledge of the sciences. It relies on effective reasoning, decision making, and communication shared by all health professionals, including physicians, nurses, dentists, pharmacists, physiotherapists, and administrators.

A Primer on Clinical Experience in Medicine: Reasoning, Decision Making, and Communication in Health Sciences is about these essential skills. It describes how physicians and health professionals reason, make decisions, and practice medicine. Covering the basic considerations related to clinical and caregiver reasoning, it lays out a roadmap to help those new to health care as well as seasoned veterans overcome the complexities of working for the well-being of those who trust us with their physical, mental, and spiritual health.

The book provides a step-by-step breakdown of the reasoning process for clinical work and clinical care. It examines both general and medical ways of thinking, reasoning, argumentation, fact finding, and using evidence. Outlining the fundamentals of decision making, it integrates coverage of clinical reasoning, risk assessment, diagnosis, treatment, and prognosis in evidence-based medicine. It also:

  • Describes how to evaluate the success (effectiveness and cure) and failure (error and harm) of clinical and community actions
  • Considers communication with patients and outlines strategies, successes, failures, and possible remedies—including offices, bedside, intervention, and care settings
  • Examines strategies, successes, failures, and possible remedies for communication with peers—including interpersonal communication, morning reports, rounds, and research gatherings

The book describes vehicles, opportunities, and environments for enhanced professional communication, including patient interviews, clinical case reports, and morning reports. It includes numerous examples that demonstrate the importance of sound reasoning, decision making, and communication and also considers future implications for research, management, planning, and evaluation.

Table of Contents

Ways We See, Learn, and Practice Medicine Today: Paradigms of What We Are Doing
Executive Summary
Not-So-Random Leading Thoughts
Introductory Comments
Art, Science, and Craft of Medicine
     Medicine as Art
     Medicine as Science
          Scientific Theory
          Scientific Method
     Medicine as Craft
Deterministic vs. Probabilistic Paradigm of Medicine: Uncertainty, Fuzziness, and Chaos
     Probability and Clinical Uncertainty
     Fuzzy Theory
     Chaos Theory in Medicine
Medicine as Philosophy: Philosophy in Medicine and Philosophy of Medicine 
     Philosophy in Medicine
     Philosophy of Medicine
Practice and Theory of Medicine: Which One Will You Learn?
     Practice of Medicine
     Theory of Medicine
Evidence-Based Medicine and Other Evidence-Based Health Sciences
Beyond the Original Concept of Evidence-Based Medicine: Evidence-Based Critical Thinking Medicine and Reflective Uses of Evidence 
     Critical Thinking
     Reflective Uses of Evidence
Conclusions: What Exactly Should We Teach and Learn Then?

How Physicians and Other Health Professionals Really (or Should) Think
Executive Summary
Not-So-Random Leading Thoughts
Introductory Comments
General Medical Thinking and Reasoning
     Basic Considerations Related to Clinical Care and Caregivers’ Reasoning 
     Our Thinking and Reasoning: Essential Definitions and Meanings 
     Tools for Argumentation
          "Naked" Argument (Enthymeme) or Argument at Its Simplest: A "Two-Element" Reasoning 
          "Classical" Form of Reasoning: Categorical Syllogism or "Three-Element" Reasoning 
          "Modern" Form of Toulmin’s Model of Argument: A "Multiple (six-) Element" Way of Reasoning to Reach Valid Conclusions 
     Reminder Regarding Some Additional and Fundamental Considerations
Challenges of Causal Reasoning within the General Context of Medical Thinking and Reasoning 
     Causal Reasoning in a Quantitative and Qualitative Way
          How We Look at Causes: Single or Multiple-Sets, Chains, Webs, Concept Maps
          Ways of Searching for Causes
          Criteria of Causality
          Disease or Event Frequencies and Fractions in Causal Reasoning 
          Beyond Causality: Combining Frequencies, Fractions, Risks, and Proportions 
          Quantifying Our Uncertainties
Fallacies in Medical Reasoning and Scientific Thinking in General
Role of Causal Reasoning in Medical Thinking
Critical Thinking, Communication, and Decision Making and Their Connection to Medical Ethics

Reasoning in Step-by-Step Clinical Work and Care: Risk, Diagnosis, Treatment, and Prognosis
Executive Summary
Not-So-Random Leading Thoughts
Introductory Comments
"You Are at Risk." What Does This Mean and How Can It Be Mutually Understood by Us, Our Patients, and the Community? 
     What Is "Risk" in Health Sciences?
     Are Risk Characteristics All the Same? Risk Factors and Risk Markers 
     Why Are Some Risk Factors "Significant" and Others Not?
     Where Does Our Knowledge of Risk Factors and Markers Come From? 
     Risk as a Subject of Argumentation
     Illustrative Fallacies
     How Do We Think about Risk? Our Ways of Reasoning about Risk
"We Have a Problem Here": Properties of Meaningful Diagnosis
     Quality and Completeness of the Diagnostic Material
     How Is a Diagnosis Made?
     How Good Are Our Diagnostic Methods and Techniques? 
     Diagnosis as a Subject of Argumentation
     Illustrative Fallacies
     How Do We Think and Reason in the Diagnosis Domain?
"That’s What We’ll Do about It": Reasoning and Deciding How to Treat and if the Treatment Works 
     Types and Levels of Medical Therapeutic and Preventive Interventions 
     Which Treatment Works Best? How Is It Measured?
     Which Treatment Modality Applies to a Particular Patient? 
     Treatment as a Subject of Argumentation
     Illustrative Fallacies
     How Do We Reason in the Domain of Treatment and Preventive Intervention?
Reasoning about Prognosis: "You’ll Be Doing Well" … Making Prognosis Meaningful 
     Differences between the Prognosis Domain and the Risk Domain 
     What Do We Need to Know about Prognostic Events and Outcomes? 
     What Do We Expect from Prognostic Studies in Order to Reason More Effectively about the Future of Our Patients? What Treatment Modality Best Applies to a Particular Patient? 
          How Should We Apply What We Know to an Individual Patient? 
     Prognosis as a Subject of Argumentation 
     Illustrative Fallacies 
     How Do We Think in the Domain of Prognosis? Considerations for Further Work and Understanding in the Area of Prognosis

Clinical and Community Medicine Decision Making
Executive Summary
Not-So-Random Leading Thoughts
Introductory Comments
Decision Theory, Decision Analysis, and Decision Making in General and in Medicine
How Decisions Are Made in Daily Life
     Direction Searching Tools through Unstructured Ways of Decision Making 
     Direction Searching Tools through Structured Ways of Decision Making 
          Decision Analysis
          Cost–Benefit/Effectiveness/Utility Analysis in Clinical Decision Making 
          Decisions as Conclusions of an Argumentative Process
     Direction-Giving Tools in Decision Making
          Tactical Tools: Clinical Algorithms
          Evidence-Based Clinical Decision Path
          Strategic Tools for Making the Right Decisions: Clinical Practice Guidelines and Clinical Protocols
Illustrative Fallacies in the Decision-Making Domain
      Fallacies from an Individual Perspective: Individual-Related Fallacies 
          Reasoning-Based Fallacies: Fallacies Related to the Thinking Process behind Decision Making
          Fallacies from the Motivation to Decide Domain
          Fallacies Related to Decisions Themselves
     Collective-Related Fallacies: Groupthink

How Physicians Communicate with Themselves, Their Patients, and Others: Clinical Communication and Its Vehicles
Executive Summary
Not-So-Random Leading Thoughts
Introductory Comments
How to View Communication in General and in Its Medical Context 
Intellectual Vehicles of Communication: Some Less and Some More Interrogative Ways of Sharing Knowledge and Experience 
     Barking Orders
     Just Watch Me!
     Do It after Me!
     Pimping: A Refined Form of Bullying
     Uttering Wisdom
     Argumentation and Critical Thinking-Based and Evidence-Grounded Exchange of Data and Information: A "What Do You Think?" Type of Medicine I 
     Socratic Dissent—A Refined Form of Pimping: A "What Do You Think?" Medicine II
Instrumental Vehicles, Opportunities, and Environments for Professional Communication: Oral and Written Exchanges of Experience in Clinical Practice 
     Patient Interviews: Admission and Opening Patients’ Charts
          Verbal, Oral, and Written Communication
          Nonverbal Communication
     Revisiting the Patient: Updating Opening Interview and Record through Bedside Communication and Progress Notes (SOAPs) 
     Narratives and Clinical Case Reports
          Clinical Consultations as Narratives
          Clinical Vignettes and Clinical Case Reports
     Morning Reports
     Morbidity and Mortality Reports and Rounds
     Journal Clubs
     Other Types of Rounds
     Mostly One-Way Communication Vehicles: Consults, Referrals, Discharge Notes, and Summaries 
     Scut Work
     Formal (Magisterial) Lectures
     Medical Articles and Other Scientific Papers
     Other Forms of Communication
Illustrative Fallacies in Communication
     Slippery Slope Fallacy (Domino Theory, Argument of the Beard, Barefoot, Beard Fallacy, Domino Fallacy, Reductio Ad Absurdum, Slippery Slope Argument) 
     Gambler’s Fallacy
     Appeal to Consequences Fallacy (Wishful Thinking)
     Self-Evidence Fallacy (Mystical Assertion, Blind Conviction) 
     Appeals to Anything Other Than the Best Evidence ("Low Instincts") 
     Alternative Choice Fallacy
      Complementary Treatment Fallacy
     Blinding with Science Fallacy
Conclusion: From Patient Problem Solving Dialogue to a Broader Communication by Knowledge Translation in Medicine

Conclusions (with a Short Recapitulation): Welcome to the World of Reasoned and Evidence-Based Medicine
Glossary: Preferred Terms and Their Definitions in the Context of this Book

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Milos JENICEK, MD, PhD, Canadian citizen, is currently holding a position as Professor (Part-Time) at the Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada. He is also Professor Emeritus at the University of Montreal and he holds an adjunct position of Professor at McGill University Faculty of Medicine, Montreal, Quebec, Canada. In 2009, he was elected Fellow of The Royal Society of Medicine, London, UK.

Milos Jenicek received his basic education at Charles University, Prague (MD, 1959), a graduate degree in 1965 (PhD) and later a postgraduate clinical training at McGill University Teaching Hospitals. He is a licentiate of the Medical Council of Canada (LMCC), a Fellow of the Royal College of Physicians and Surgeons of Canada (FRCPC), a specialist of the Province of Quebec (CSPQ) and holds a regular permit to practice medicine in Ontario and Quebec.

He contributes to the evolution of epidemiology as a general method of objective reasoning and decision making in medicine. To further enhance his teaching and research, he has committed himself to short sabbaticals during which he visited Harvard and Johns Hopkins, Yale, North Carolina at Chapel Hill and Uniformed Services at Bethesda Universities. He also lectured and visited numerous institutions in Hong Kong, Singapore, Japan, South Korea, Portugal, Brazil, France and Switzerland. He has been a visiting professor to various universities and governments. Earlier in his career, three years of University teaching and field practice of preventive medicine and public health in North Africa (1965-1968) has given him valuable insight and understanding of the realities in this part of the world.

During his term as Acting Chairman of the Department of Social and Preventive Medicine, University of Montreal (1988-1989), he founded the graduate program in Clinical Epidemiology at the University of Montreal, his core course being also part of the graduate program at McGill University. Until 1991, he was member of the Board of Examiners of the Medical Council of Canada (Committee on Preventive Medicine). In 2000, he was invited as External Examiner by the Kuwait University. Also, Milos Jenicek is a consultant to various national and international public and private bodies, Editorial Consultant for the Journal of Clinical Epidemiology and the Case Reports & Clinical Practice Review and Honorary Editorial Board Member of Evidence-Based Preventive Medicine.

In addition to numerous scientific papers, Milos Jenicek has published thirteen textbooks: Introduction to Epidemiology (in French, 1975). Epidemiology. Principles, techniques, applications (in French with R. Cléroux, 1982, and in Spanish, 1987), Clinical Epidemiology, Clinimetrics (in French with R. Cléroux, 1985), and Meta-Analysis in Medicine. Evaluation and Synthesis of Clinical and Epidemiological Information (in French, 1987), by the James Lind Library recognized first textbook of meta-analysis in medicine. The Epidemiology. The Logic of Modern Medicine" (EPIMED International,1995) was also published in Spanish (1996) and Japanese (1998). His sixth book, Medical Casuistics. Proper Reporting of Clinical Cases" (in French, 1997) is again produced jointly by Canadian (EDISEM) and French (Maloine) publishers. Clinical Case Reporting in Evidence-Based Medicine (Butterworth Heinemann,1999) appears again as an expanded second edition in English (Arnold, 2001), Italian (2001), Korean (2002) and Japanese (2002). His Foundations of Evidence-Based Medicine was published in 2003 by Parthenon Publishing/CRC Press. The tenth Evidence-Based Practice. Logic and Critical Thinking in Medicine (with D Hitchcock) was released by the American Medical Association (AMA Press, 2005) as well as his A Physician’s Self-Paced Guide to Critical Thinking (AMA Press, 2006) and Fallacy-Free Reasoning in Medicine. Improving Communication and Decision Making in Research and Practice (AMA Press, 2009). His Medical Error and Harm. Understanding, Prevention, and Control was just released (2011) by CRC Press/Taylor & Francis.

Current interests: Development of methodology and applications of logic, critical thinking, decision making and communication in health sciences, enhancement of evidence-based medicine and evidence-based public health, health policies and program evaluation, decision oriented (bedside) clinical research.

Contact by e-mail: [email protected]


…a timely book.Jenicek illustrates how three distinct areas—medical reasoning, decision making, and multiple aspects of communication—can be systematically approached using the argumentation framework. … a primer on how physicians reason, but also useful to practicing physicians and even teachers who have not undergone formal training in thinking. … In his gentle and engaging way, with occasional humor thrown in, Jenicek takes the reader through the essentials.
—Pat Croskerry, MD, PhD, Dalhousie University, Halifax, Nova Scotia, Canada