1st Edition

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

By Milos Jenicek, MD Copyright 2013
    368 Pages 20 B/W Illustrations
    by CRC Press

    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.

    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


    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