LO2

Make safe clinical decisions, appropriate to level of experience, knowing when and how to seek effective support

This ACCS Learning Outcome incorporates an understanding of the key steps in diagnostic reasoning, how clinicians make decisions and the factors that have a negative or positive impact on this fundamental skill. The trainee will develop an understanding of how to recognise and mitigate against cognitive errors that can cause harm and threaten patient safety. Good clinical knowledge remains key and the trainee will be able to apply the core principles of evidence based medicine to everyday clinical problems. This will extend to understanding how safe plans can be formulated, including deciding to discharge patients. It is equally important to recognise one’s limitations and know when to ask for help, which needs to be demonstrated appropriately.

At completion of LO2 a trainee will be able to:

Understand how to apply clinical guidelines.
Understand how to use diagnostic tests in ruling out key pathology, and be able to describe a safe management plan, including discharge where appropriate, knowing when help is required.
Be aware of the human factors at play in clinical decision making and their impact on patient safety.

Descriptors:

Proficient in ECG and plain film interpretation, as relevant to acute care.
Aware of the cognitive psychology of decision making.
Understand basic diagnostic test methodology.
Understand the fundamentals of decision rule design.
Aware of the strengths and limitations of using guidelines e.g. NICE
Demonstrate capabilities in dealing with complexity and uncertainty.
Share decision making by informing patients, prioritising patient’s wishes, and respecting their beliefs, concerns and expectations.

Programme of learning:

Trainees will be required to record evidence of grounding in the theoretical underpinnings of clinical reasoning.

Resources include:

RCEM learning material
Local and regional teaching to cover this ACCS LO
Simulation/ human factors training on decision making

Evidence to inform decisions:

Mini-CEX
CbD
ACAT
Logbook
FEG
MCR
MSF
Patient feedback

Assessment:

ACCS trainees will have the opportunity to receive focussed feedback in this Learning Outcome with patients they review. Formative assessment should focus on trainee commitment to a decision that can be probed and opportunities to explore reasoning, or the use of diagnostic tests and guidelines. WPBA is also an opportunity to test background learning in cognitive decision making at this stage, and trainees will be expected to reflect on this following clinical encounters where decision making has been explored.

Entrustment Decisions:

Although trainees will not need to be entrusted to answer clinical questions at the end of ACCS, they will need to be entrusted to ask questions based on sound underpinnings, i.e. demonstrate an understanding of key principles such as diagnostic methodology, cognitive bias, how decision rules and guidelines work and are best used.

Level 2a

- RCEM Learning - Human Factors
- Review of the Basics of Cognitive Error in Emergency Medicine
  - This article explores how cognitive errors can lead to medical mistakes in emergency settings. It discusses dual-process theory, cognitive biases, and strategies to mitigate errors.
- Cognitive Biases Encountered by Physicians in the Emergency Room
  - This study identifies common cognitive biases in emergency medicine, such as overconfidence, confirmation bias, availability bias, and anchoring. Understanding these biases can help in making more accurate clinical decisions.
- What Cognitive Psychology Tells Us About Emergency Department Physician Decision-making and How to Improve It
  - This article examines how cognitive psychology principles apply to decision-making in emergency departments and suggests methods to enhance decision-making processes.
- Decision Making in Emergency Medicine: We Can't Escape Bias
  - This resource discusses the impact of cognitive biases on decision-making in emergency medicine and offers insights into recognizing and addressing these biases.
- Cognitive Forcing Strategies in Clinical Decision-making
  - This article introduces cognitive forcing strategies designed to help clinicians avoid common cognitive errors, thereby improving diagnostic accuracy in emergency settings.
- Cognitive Biases and Mitigation Strategies in Emergency Diagnosis
  - This resource provides an overview of cognitive biases in emergency diagnosis and discusses strategies to mitigate their effects, enhancing clinical decision-making.
- Gerd Gigerenzer's Work on Heuristics and Decision-Making
  - Gerd Gigerenzer's research focuses on how simple heuristics can lead to effective decision-making, even in complex and uncertain environments like emergency medicine. His work challenges the traditional view of cognitive biases and emphasizes the adaptive nature of human decision-making.
- RCEMLearning: Appraising a Diagnostic Test – D-Dimer
  - This module introduces the approach to appraising diagnostic tests, using D-Dimer as a case study. It covers the performance characteristics of diagnostic tests, including sensitivity, specificity, and predictive values.
- RCEM Common Competencies: Decision Making and Clinical Reasoning
  - This document outlines the competencies required for effective decision-making and clinical reasoning in EM. It emphasizes the importance of understanding diagnostic test methodology in formulating diagnostic and therapeutic plans.
- RCEM Quality Improvement Guide
  - This guide provides an introduction to quality improvement (QI) in EM, including the role of diagnostic tests in enhancing patient care. It discusses the basic science of QI and offers practical tools for clinicians undertaking QI projects.
- Diagnostic Testing in the Emergency Department – SAEM
  - The Society for Academic Emergency Medicine (SAEM) offers resources on diagnostic testing in the ED. This resource discusses the evolution of diagnostic testing in emergency settings and the importance of selecting appropriate tests based on clinical suspicion and patient presentation.
- Evidence-Based Emergency Care: Diagnostic Testing and Clinical Decision Rules
  - This book provides a concise compilation of the evidence supporting diagnostic testing and clinical decision rules in emergency care. It covers the science of diagnostic testing and reviews the process behind the development of clinical decision rules.
- Modern Diagnostics in Emergency Medicine – PMC
  - This article offers an overview of emergency diagnostics, discussing the challenges and advancements in diagnostic methods within the field. It emphasises the importance of rapid and accurate diagnostics in emergency settings.
- Diagnostic Testing and Clinical Decision Rules – Wiley
  - This resource delves into the science of diagnostic testing and the development of clinical decision rules, providing insights into their application in emergency care.
- RCEM Curriculum 2021
  - The RCEM Curriculum outlines the competencies required for EM practitioners, including an understanding of decision rule design. It provides a comprehensive framework for the skills and knowledge expected at various stages of training.
- RCEM Quality Improvement Guide
  - This guide offers insights into quality improvement processes within EM, highlighting the importance of evidence-based decision-making and the development of clinical decision rules. It includes practical strategies for implementing changes in clinical practice.
- "Rules of Thumb" for Medical and Practitioner Staffing in Emergency Departments
  - While primarily focused on staffing, this document discusses the application of decision rules in resource allocation and service delivery within EM departments. It provides context on how decision rules can influence operational efficiency.
- "Top 30 Emergency Medicine Research Priorities 2017"
  - This document identifies key areas for research in EM, including the development and implementation of clinical decision rules. It offers insights into current priorities and the evidence base supporting decision rule design.
- "A Practical Guide to Flexible Working and Good EM Rota Design"
  - Although focused on rota design, this guide discusses the application of decision rules in workforce planning and scheduling within EM departments. It provides practical examples of how decision rules can be applied to improve service delivery.
- "Urgent and Emergency Care Clinical Audit Toolkit"
  - This toolkit provides a framework for conducting clinical audits in urgent and emergency care settings, emphasizing the role of decision rules in standardizing and improving clinical practice. It includes methodologies for evaluating the effectiveness of decision rules.
- "EMLeaders Framework"
  - The EMLeaders Framework outlines the leadership competencies required in EM, including the ability to develop and implement decision rules. It provides guidance on integrating decision rule design into leadership and management practices within EM.
- RCEM Curriculum 2021
  - The Royal College of Emergency Medicine (RCEM) curriculum outlines the competencies required for emergency medicine practitioners, including an awareness of the strengths and limitations of using guidelines like NICE. This resource provides a comprehensive framework for the skills and knowledge expected at various stages of training.
- "From guidance to practice: Why NICE is not enough"
  - This article discusses the role of NICE in providing consistent and timely guidance on best practices within the NHS. It highlights the importance of implementing NICE guidance within a supportive system and addresses challenges in translating guidelines into practice.
- "Challenges for the National Institute for Clinical Excellence"
  - This paper examines the challenges faced by NICE, including the lack of a set threshold for approving treatments, which can lead to the approval of therapies with small benefits. It discusses the implications of these challenges for healthcare providers and decision-makers.
- "The advantages and limitations of guideline adaptation frameworks"
  - This study explores the use of guideline adaptation frameworks, providing a systematic approach to adapting guidelines to local contexts. It discusses the strengths and limitations of these frameworks in ensuring the relevance and applicability of guidelines.
- "NICE guideline has weaknesses"
  - This article critiques a specific NICE guideline, highlighting areas where the guideline may lack empirical evidence or may not align with current best practices. It emphasizes the need for continuous evaluation and adaptation of guidelines to ensure their effectiveness.
- RCEM Curriculum 2021
  - The Royal College of Emergency Medicine (RCEM) curriculum outlines the competencies required for EM practitioners, including the ability to manage complexity and uncertainty. This resource provides a comprehensive framework for the skills and knowledge expected at various stages of training.
- "Being explicit about the uncertainty of clinical practice in training"
  - This article discusses the impact of developing and nurturing a tolerance of uncertainty in clinical practice on the well-being and clinical acumen of clinicians and trainees. It emphasizes the importance of acknowledging and addressing uncertainty in medical training.
- "Coping with uncertainty in clinical practice: a narrative review"
  - This review explores how clinicians respond to uncertainty through cognitive, emotional, and ethical reactions. It highlights the significance of understanding and tolerating clinical uncertainty as core clinical competencies for medical graduates and trainees.
- "SLO 7 - Deal with complex or challenging situations in the workplace"
  - This resource from the RCEM Specialty Learning Outcomes (SLOs) focuses on the capability to handle complex or challenging situations in the workplace. It provides guidance on managing such scenarios effectively.
- "A conceptual mental model for decision making in emergency care"
  - This paper addresses a conceptual mental model for emergency care that combines both analytic and non-analytic methods in decision-making. It offers insights into navigating complex and uncertain clinical environments.
- "Making decisions 'in the dark': Learning through uncertainty in clinical practice"
  - This study explores how decision-making and informal and incidental learning emerge in the clinical learning environment during times of heightened uncertainty, such as the COVID-19 pandemic. It provides perspectives on learning to navigate complex clinical challenges.
- "Navigating Uncertainty in Clinical Practice: A Workshop to Prepare Medical Students"
  - This resource offers a novel application of a sense-making framework and taxonomy for medical students to classify uncertainty. It provides strategies for problem-solving when working through clinical uncertainty.
- RCEM Curriculum 2021
  - This curriculum outlines the competencies required for emergency medicine practitioners, including patient communication and shared decision-making. It provides a comprehensive framework for the skills and knowledge expected at various stages of training.
- "Communicate, Communicate, Communicate" – RCEMLearning
  - This module emphasises the importance of compassionate and effective communication in emergency medicine. It offers practical tips and strategies for engaging with patients, prioritising their wishes, and respecting their beliefs and concerns.
- "Shared Decision Making for the Emergency Provider" – MedEdPORTAL
  - This resource provides a structured approach to shared decision-making (SDM) in the emergency setting, including a framework and role-playing scenarios to practice engaging patients in their care decisions.
- "Shared Decision making in the Emergency Department: A Guiding Framework" – PubMed Central
  - This article discusses the principles of SDM in the emergency department, offering a framework for clinicians to involve patients in decision-making processes.
- "The SHARE Approach: Steps of Shared Decision Making" – Agency for Healthcare Research and Quality (AHRQ)
  - The SHARE Approach is a five-step model designed to facilitate SDM. It includes seeking patient participation, helping patients explore and compare healthcare options, assessing their values and preferences, reaching a decision together, and evaluating the decision.
- "A Guide to Employing Shared Decision Making in Clinical Practice" – ACP Decisions
  - This guide offers practical steps for implementing SDM, emphasising the importance of understanding and respecting patient values and preferences in the decision-making process.

Page Contributors

Dr Sunny Jutla
Consultant in Emergency Medicine, Lead for EM3

Tom Brown
Website Designer

Jake Fudge
Multimedia Technologist