Deduction, Induction and the Art of Clinical Reasoning in Medical Education: Systematic Review and Bayesian Proposal

de-Sousa, Marcos Roberto; Aguiar, Túlio Roberto Xavier de

doi:10.36660/abc.20220405

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Original Article • Arq. Bras. Cardiol. 119 (5 suppl 1) • Oct 2022 • https://doi.org/10.36660/abc.20220405 linkcopy

Deduction, Induction and the Art of Clinical Reasoning in Medical Education: Systematic Review and Bayesian Proposal

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background Clinical reasoning is at the core of medical practice and entangled in a conceptual confusion. The duality theory in probability allows to evaluate its objective and subjective aspects.

Objectives To conduct a systematic review of the literature about clinical reasoning in decision making in medical education and to propose a “reasoning based on the Bayesian rule” (RBBR).

Methods A systematic review on PubMed was conducted (until February 27, 2022), following a strict methodology, by a researcher experienced in systematic review. The RBBR, presented in the discussion section, was constructed in his undergraduate dissertation in Philosophy at Minas Gerais Federal University. Heart failure was used as example.

Results Of 3,340 articles retrieved, 154 were included: 24 discussing the uncertainty condition, 87 on vague concepts (case discussion, heuristics, list of cognitive biases, choosing wisely) subsumed under the term “art”, and 43 discussing the general idea of inductive or deductive reasoning. RBBR provides coherence and reproducibility rules, inference under uncertainty, and learning rule, and can incorporate those vague terms classified as “art”, arguments and evidence, from a subjective perspective about probability.

Conclusions This systematic review shows that reasoning is grounded in uncertainty, predominantly probabilistic, and reviews possible errors of the hypothetico-deductive reasoning. RBBR is a two-step probabilistic reasoning that can be taught. The Bayes theorem is a linguistic tool, a general rule of reasoning, diagnosis, scientific communication and review of medical knowledge according to new evidence.

Education, Medical; Problem Solving; Learning; Clinical Decision-Making; Systematic Review; Bayes Theorem; Evidence Based Medicine

Author, Year	Type of publication	Main argument
Whitehorn, 1963	Expert’s opinion	Against determinism, in favor of probability and values.
Elstein, 1982	Editorial	A proposal to deal with uncertainty: “More time is spent on the computation and interpretation of chi-squares, T-tests, and other inferential techniques than on the statistics of opinion revision and decision making – the so-called Bayesian approach – though the latter is more relevant to the daily work of clinical practice (…). Clinical practitioners are properly more concerned with the soundness of decisions made in particular circumstances than with the soundness of general inferences. For this purpose, the Bayesian outlook will be more helpful, and instruction in the logic of clinical decisions should incorporate it.”
Gunderman, 2005	Expert’s opinion	A dialogic proposal to deal with uncertainty.
Nevalainen et al., 2009	22 students' reflective learning diaries	Reflective writing as a proposal to express and deal with uncertainty.
Blanch et al., 2009	147 interactions between medical students and patients	The authors found a negative perception of medical students who expressed uncertainty to patients. Types of sentences were analyzed.
Charlin et al., 2010	Panel with experts, residents and students	Standardization methods to compare scores of individual examiners with those of a reference panel to deal with uncertainty.
Schwartz, 2011	Expert’s opinion	A proposal to teach decision making as the main question in medicine.
Hamui-Sutton et al., 2015	128 Residents: interview and expert’s opinion	A comprehensive evaluation of several types of uncertainty in medical practice.
Niedermier, 2016	Letter to the editor	Points to the negative effects of uncertainty and the need to deal with it.
Simpkin et al., 2016	Expert’s opinion	Speak about “hypotheses” rather than “diagnoses”, embracing uncertainty as an attitude.
Cooke et al., 2017	594 trainees	Uncertainty stress and reluctance in communicating uncertainty.
Cooke et al., 2017	Expert’s opinion	A proposal to embrace uncertainty and accept more than one solution to a problem.
Oferta, 2017	Expert’s opinion	Literature, music, art and humanities to learn to deal with uncertainty.
Kim et al., 2018	Review	Proposal of strategies to manage uncertainty.
Simpkin et al., 2018	86 Interviews with residents and expert’s opinion	High levels of uncertainty stress and low levels of resilience seem to be associated with depression and burnout.
Tonelli et al., 2019	Expert’s opinion	Philosophical approach of uncertainty, including metaphysics, fallibilism, and epistemological reasoning.
Davidson, 2019	Editorial	A set of recommendations to deal with uncertainty in medical science: “Authors should be appropriately tempered in their conclusions, using language that acknowledges uncertainty where appropriate. The conclusions should be influenced by not only the P value but also the effect size and bounds of the 95% confidence intervals."
Ying et al., 2019	70 residents	The study suggested that individuals that are more comfortable with uncertainty can experience greater satisfaction at work.
Stephens et al., 2020	Qualitative study with 608 students	Motivate medical educators to incorporate aspects of tolerance to uncertainty in academic and learning environments.
Beck et al., 2020	Expert’s opinion	A dialogic proposal to deal with uncertainty.
Lee, 2020	Editorial	A call for articles on uncertainty motivated by the COVID-19 pandemic.
McCarthy et al., 2020	Randomized trial comparing communication strategies in disclosing diagnostic uncertainty	Educational intervention for clear communication about diagnostic uncertainty to improve quality of care at the emergency department.
Papanagnou et al., 2021	Observational cross-sectional study with third-year medical students	The students were surveyed for the development of trainings to deal with uncertainty.
Romiti et al., 2021	Expert’s opinion	The authors argued that the COVID-19 pandemic intensified our conflicting relationship with uncertainty.

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