CRITICAL THINKING IN CLINICAL

DECISION MAKING
DR. CHEW KENG SHENG
Module 5
Question #1

• Jack is looking at Anne,

but Anne is looking at
George. Jack is married,
but George is not. Is a
married person looking
at an unmarried person?
A. Yes
B. No
C. Cannot be determined
Disjunctive Reasoning

• Would you have answered differently if

the options are only Yes or No?
• This thought process is called fully
disjunctive reasoning – reasoning that
considers all possibilities
• Most people can carry out fully disjunctive
reasoning when they are explicitly told
that it is necessary but most do not
automatically do so.
Discuss further

Does it make a difference in your decision

making process if you have only option A
and option B as compared to if you are
given option C as well (which essentially is
a permission or excuse not to make a
definite choice on the basis of “inadequate
information given”)?
 “Humans are cognitive misers
because our basic tendency is to
default to the processing
mechanisms that require less
computational effort, even if they are
less accurate” – Keith Stanovich,
cognitive psychologist
Question #2

• Suppose you want to

buy a book and a
pencil. The book and
the pencil cost $1.20
in total. If the book
costs $1.00 more
than the pencil, how
much does the
pencil cost?
Discuss further

• Discuss on intelligence vs Rationality

• “We often assume intelligence and
rationality go together but we shouldn’t be
surprised when smart people do foolish
things” – Keith Stanovich
• Dysrationalia – is the inability to think and
behave rationally despite having
adequate intelligence
What does the middle character look like?
Which line is longer?
How do we make decisions?

• Decision making is one of the most

important we do, it is the engine that
drives our behavior.
• We make many decisions continuously in
the course of our waking hours. These
decisions vary in complexity
• Some are relatively simple, automatic
process, well-rehearsed. Some have
consequential implications – like choosing
our life-partners
“What we are, or how we live our lives
are largely determined by the
decisions we made”

“We first make our choices, then our

choices make us”
How do we make decisions?

• One of the major developments in

cognitive psychology over the last 20
years is the dual process theory (DPT) of
reasoning.
• The DPT of reasoning has emerged as
the dominant theory of reasoning
particularly through the works of people
like Epstein, Tversky and Kahneman,
Stanovich and West, and Evans.
Dual-process thinking

• According to the DPT of reasoning, there

are two modes of decision making, i.e.,
System 1 and System 2.
• System 1 is the fast, intuitive, reflexive,
automatic and frugal thinking and it is
where we spend most of our time making
most of our decisions. Driving a car for
someone who has been driving for a long
time is an example of System 1 thinking.
Dual-process thinking

• System 2, on the other hand is a

deliberate, analytical, purposeful or
effortful form of thinking that is usually
slower.
• Discuss: give further examples of some of
the decisions that you make in your daily
lives that are largely based on System 1
and those that are based on System 2
Dual-process thinking

System 1 (Intuitive) System 2 (Analytical)

Experiential-inductive Hypothetico-deductive
Heuristic Systematic
Pattern recognition Robust decision making
Unconscious thinking theory Deliberate, purposeful
thinking
Fast Slow
High capacity Limited
High emotional attachment Low emotional attachment
Low scientific rigor High scientific rigor
System 1 and System 2 in play
Cognitive biases

• While heuristics are helpful cues for

System 1, at times, they are prone to
cognitive biases and errors.
• Cognitive biases or cognitive disposition
to respond are our predictable
tendencies to respond in a certain way to
the contextual clues at that time
• These biases are often unconsciously
committed, and may result in flawed
reasoning
Availability bias

• Availability bias – this refers to our

tendency to judge things as being more
likely, or frequently occurring, if they
readily come to mind.
Anchoring

• Anchoring – this refers to our tendency to

fixate our perception on to the salient
features in the initial information so much
so that we fail to adjust our initial
impression even in light of later
information.
Confirmation bias

• Confirmation bias – this refers to our

tendency to look for confirming evidence
to support the decision we are
“anchoring” to, while downplaying, or
ignoring or not actively seeking evidences
that may point to the contrary.
Search satisficing

• This refers to our tendency to stop

looking or call off a search for a second
possibility when we have found the first
one.
Sunk cost fallacy/bias

• The more a we invest in a particular

decision, the less likely is it to change it
and consider alternatives. This form of
entrapment is common in financial
investment.
Sunk cost fallacy/bias
Ego bias

• This refers to our tendency of

overestimating the success of one’s
own decisions compared to that of a
population of similar decisions by
others.
Blind spot bias

• This refers to the bias that many people

have where they believe that they are
less susceptible to errors compared to
others. This has some similarities with
ego bias.
Hindsight bias

• With hindsight bias, we discount the

uncertainty in which a past decision
was taken once its outcome is known –
‘I always knew’ or ‘I told you so’.
Hindsight bias

• However, it is not necessarily true that

just because the outcomes are bad, the
decisions are bad too, as people
generally do not deliberately make bad
decisions.
• The decisions taken at that time must
have made sense to them.
Overconfidence bias

• It refers to our universal tendency to

believe that we know more than we do.
• Overconfidence reflects a tendency to act
upon incomplete information, intuitions, of
hunches.
Gambler’s fallacy

• The concept of this bias is borrowed from

the gambling situation where if a coin is
tossed ten times, and for every case of
the toss, head is shown.
• A person with gambler’s fallacy will say
that if the coin is tossed for the 11th time,
there must be a greater chance of being
tail.
Gambler’s fallacy

• However, the coin has no memory and

the coin actually has a 50-50 chance of
showing tail in each toss, which is
independent of the previous outcomes.
Gambler’s fallacy

• When the 6th patient with shortness of

breath arrives in the emergency
department, a clinician with this fallacy
will probably think that for this 6th time,
the patient must be having a condition
other than pneumonia, such as asthmatic
attack.
Posterior probability error

• This is the opposite of gambler’s fallacy.

In this bias, if a clinician sees five patients
with shortness of breath in the course of a
working shift, which turn out to be
pneumonia in every cases; when the 6th
patient with shortness of breath arrives in
the emergency department, the tendency
is to believe that this patient must be
having pneumonia as well.
Critical Thinking (1)

1. Knowing and understanding the System

1 & System 2 thinking
2. Recognizing the distracting stimuli,
biases and irrelevance affecting our
decisions
3. Identifying, analyzing and challenging
assumptions in arguments
4. Be aware of cognitive fallacies and poor
reasoning
Critical Thinking (2)

5. Recognizing deceptions – deliberate or

otherwise
6. Having the capacity for assessing the
credibility of information
7. Understand the need for monitoring and
control of our own thinking processes
8. Be aware of the critical impact of fatigue
and sleep deprivation on decision
making
Critical Thinking (3)

9. Understand the importance of monitoring

and control of our own affective states
that influence the quality of our decisions
10.Understand the context under which
decisions are made
11.Capacity to anticipate the consequences
of our decisions
Sleep deprivation

• Sleep deprivation and circadian

dysynchrony can impair performance and
reduce many aspects of human capability
including reduced attention vigilance,
impaired memory, impaired decision-
making, lagged reaction time, impaired
hand-eye coordination and disruptive
communications.
Sleep deprivation

• For example, it has been shown that after

17 hours of continuous wakefulness,
hand-eye coordination task would have
declined to such a level equivalent to that
of a blood alcohol level of 0.05%. And at
24 hour of sustained wakefulness, the
impairment in psychomotor function is
equivalent to a blood alcohol
concentration of 0.1%
Sleep deprivation

• Furthermore, a fatigued worker will also

have a tendency to slow down work his
work processes in order to maintain
accuracy (known as the “speed-accuracy
trade-off”)
De-biasing strategies

• One of the tremendous challenges in

cognitive biases is finding ways to de-bias
them. A de-biasing strategy commonly
used is called the cognitive forcing
strategies. These are deliberate,
systematic self-regulatory cognitive
mechanisms to provide a check and
balance to minimize biases.
Metacognition

• An example of cognitive forcing strategies

is metacognition. Metacognition is an
individual’s ability to stand apart from his
own thinking in order to be aware of his
own preferred learning approaches and
ultimately to manipulate his own cognitive
processes to his own advantages.
Metacognition

• In short, metacognition is “thinking about

thinking.” It allows one to ask questions
like: “How well did I do?” “What could I
have done it differently if I am given a
chance again?” etc.
De-biasing strategies

• But suppose one has the necessary

mindware, then the next question
Stanovich argues would be whether one
actually perceives a need to de-bias
them. But even if the person perceives
the need for de-biasing, the next question
would be whether the de-biasing effort
needed is a sustained effort.
De-biasing strategies

• If it is but the person does not have the

capacity for sustained de-biasing, then
the natural tendency is still to fall back
into System 1 of reasoning. This is
because when it comes to choosing the
cognitive strategies to apply for solving a
problem, we generally choose the fast,
computationally inexpensive strategy
(System 1).
• Download a free article on ‘Making
decision better’ here:
• http://tinyurl.com/cbjvjof
Authority gradient

• Another issue that may hamper the

learning and practice of critical thinking is
the issue of authority gradient.
• Authority gradient is defined as the
gradient that may exist between two
individuals’ professional status,
experience, or expertise that contributes
to difficulty exchanging information or
communicating concern.
Authority gradient

• Authority gradient is especially prevalent

in our Asian culture - which maybe
heavily influenced by Asian philosophies
of respecting the seniors.
• Such noble value is of course vitally
important in maintaining societal harmony
but can be dangerous if taken to the
extreme and junior doctor adopts an
unhealthy pessimism attitude.