The document outlines the rational use of medicines and clinical reasoning approach in patient care. It discusses common cognitive errors that can occur in clinical decision making and provides examples of irrational drug use. The summary focuses on highlighting key points about rational drug use, clinical reasoning process, and protecting against cognitive errors in diagnosis and treatment.

1. Dr Tshienda M. Denon; MB ChB [Université de Kisangani, DR Congo]
M Med [Family Medicine & Primary Health Care], MEDUNSA Campus, University of Limpopo
Department of family medicine & primary health care, Université Protestante au Congo, DRC
PhD candidate, Stellenbosch University, Cape Town, South Africa

2. FAMILY
DOCTORS PRIMARY CARE
PROFESSIONALS
DOCTORS, ALWAYS THERE TO CARE!

4. Introduction
▪ Requirements
Rational use of drugs
▪ Major global problem
▪ Clinical cases & chart review
Irrational use of drugs
▪ Introduction
▪ Pre-requisite
▪ History, physical exam,data collection
▪ Pattern recognition
▪ Errors in thinking
▪ Protecting against cognitive errors
▪ Uncertainty
▪ Patient centred-management
Clinical reasoning approach
OUTLINE

5. Patients’ quality of
life (QoL)
Better outcomes
Personal
development of
health professionals
Informative TV
series

6. Part I:
The clinical reasoning & cognitive errors
• The art and heart of medicine
Part II:
Evidence-based practice

7. Promote the rational use of medicines in our daily practice
Bring theory and
practice together
Sharpen clinical
skills of health
professionals
Raise health
professionals’
awareness about
cognitive errors

8. Medications
appropriate to patients’
clinical needs.
Adequate period of time
Doses that meet
patients’ own individual
requirements.
The lowest cost to
patients and their
community.

9. 1. WHO estimates that more than
half of all medicines are
prescribed, dispensed or sold
inappropriately, and that half of
all patients fail to take them
correctly.
2. The overuse, underuse or
misuse of medicines results in
wastage of scarce resources
and widespread health hazards.
Examples of irrational use of drugs:
▪ Use of too many medicines per
patient ("poly-pharmacy")
▪ Inappropriate use of antimicrobials,
often in inadequate dosage, for non-
bacterial infections
▪ Over-use of injections when oral
formulations would be more
appropriate
▪ Failure to prescribe in accordance
with clinical guidelines
▪ Inappropriate self-medication, often
of prescription-only medicines
▪ Non-adherence to dosing regimes
IR

10. Far-west shooting error

11. Tshienda M. Denon, Ahuka O.
Longombe.The quinine infusion
overuse in general practice,
Eastern DR Congo, Rev. Méd Gd.
Lacs 2016 June ;7(2):26-2
A multi-centre retrospective
chart review.
Data collected within health
care facilities among patients
admitted for malaria selected
randomly using a purposive
sample.
The main reasons for the quinine
intravenous infusion overuse
have been identified through
discussions during morning
staff meetings.
EVIDENCE-BASED

12. ▪ Clincial case #1
A 60 years old female patient
complaining of a headache,
myalgia, epigastralgia. No
particular findings on physical
examination. Giemsa-stained
thick blood film: 0-1 P
falciparum trophozoite per field;
white blood cells:
3,500.Conclusion: Malaria and
gastritis. Treatment: Quinine
infusion 500 mg twice a day,
Omeprazole, Paracetamol
▪ Clinical case #2
A 43 years old female patient
complaining of a headache,
weakness and edema, known as
hypertensive. Blood pressure
measurement: 200/120 mmHg.
Giemsa-stained thick blood film:
0-2 P falciparum trophozoite per
field, Widal (typhoid fever
serological test): low antibodies
levels, glycaemia: 109 mg/Dl.
Conclusion Hypertension and
Malaria. Treatment : Quinine
infusion 1g then 750 mg twice a
day, captopril, paracetamol and
ampicillin.

13. ▪ Clinical case #3
A 50 years old female patient
complaining of a weakness and
palpitation, known as
hypertensive patient. Blood
pressure measurement 160/110
mmHg. Glycaemia: 102.48
mg/dL, ESR: 12 mm/hour.
Conclusion: Hypertension.
Treatment: Quinine infusion 1 g
then 750 mg twice a day,
Diazepam, Captopril, Esidrex
▪Clinical case #4
A 22 years old female
patient complaining of an
abdominal pain and cough.
Giemsa-stained thick blood
film: 0-1 P falciparum
trophozoite per field,
urinalysis: 12-20 white cells.
Conclusion: Urogenital
infection. The patient was
admitted conveniently.
Treatment: Quinine infusion
1g then 750 mg twice a day,
Brufen, Buscopan, Zincof,
Polygynax, Ampicilline.

14. Ntamabyaliro et al.Drug use in the management of uncomplicated malaria in public health facilities
in the Democratic Republic of the Congo,Malar J (2018) 17:189 https://doi.org/10.1186/s12936-018-2332-3

16. Clinical reasoning lies at the core
of health care practice and
education
Clinical Reasoning therefore occupies a
central place in the education of health
professionals, the enhancement of
professional decision making of individuals
and groups of practitioners with their clients,
and research into optimal practice
reasoning.

17. case representation of the
problem
Patient
information
Knowledge
Clinical reasoning is a cognitive
process including the
physician’s integration of his or
her own (biomedical, clinical and
psychosocial) knowledge with
initial patient information to
form a case representation of
the problem.

18. Problem
solving
approach
Quick & efficient
decision making
« judgement »
Mental
shortcuts
« pattern
recognition »

20. ▪ Mr. J.C. is a 50 year old male
with a complaint of chest pain.
What is your differential
diagnosis?
▪Potential differential diagnosis
1. Cardiac etiology (angina, MI)
2. Pneumonia
3. Pulmonary embolism
4. GERD
Typically a complaint of chest
pain is associated with the
heart.

21. ▪ Chest pain is described as
“congestion” with associated
cough and fever.
▪Now, what is your primary
diagnosis?
1.Pneumonia
2.Pulmonary embolism
3.Cardiac etiology (angina, MI)
4.GERD

22. ▪Note the change in order
of your concerns with two
simple pieces of
information.
▪Additional patient history
will influence your
differential diagnosis and
subsequent patient
management.
▪The more information you
collect, the more accurate
your differential diagnosis
will become.
▪An accurate differential
diagnosis is the key to
developing an
appropriate work-up and
management plan.

23. Factors influencing the patient-physician
interaction will impact your ability to gather
relevant and correct information.
• Open-ended questioning
• Closed-ended questioning
• Transference
• Counter-transference

24. Asking questions
▪ Open-ended questions:
encourage a spontaneous
response.
▪ A spontaneous response will
increase the likelihood of
gathering an accurate history
from your patient.
▪ Closed-ended questions:
lead the patient to a specific
answer.
Unspoken communication
▪ Transference: is your
expectation of the patient,
based on prior patient
interaction and experiences.
▪ Counter-transference: is
the patient’s expectation of
you, based on previous
physician interaction and
experiences.

25. ▪Your patient expectations
and how questions are
asked will significantly
impact the quality of your
patient history.
▪Making an accurate
diagnosis depends on a
good patient history.
▪Subsequent patient
management decisions are
dependent on your patient
history.
▪As a general rule, the
correct diagnosis should
be part of your
differential diagnosis
based on patient history
alone.
▪Physical exam helps to
confirm your primary
diagnosis and narrows
down your differential.

26. The basis of clinical diagnosis is
pattern recognition, a process
known as “heuristics”
• Heuristics were subconsciously utilized in
our brief clinical case.
An experienced physician will
make rapid and accurate
diagnoses based on pattern
recognition.
• Koplik spots,fever and skin rash → measles

27. Clinical decision-making
through heuristics is prone to
associated errors in thinking.
An incorrect diagnosis can
lead to potentially harmful
management of your patient.

28. This occurs when the pattern of disease does not fit the
typical disease presentation.
A common disease presenting uncommonly.
i.e.Myocardial infarction in a diabetic patient without chest pain.

29. This occurs when a disease presentation
does not fit a recognized pattern of
disease.
An uncommon disease presenting
commonly.
• i.e. Giant cell arteritis mistaken for a simple tension
headache.

30. This occurs when a patient fits a negative
stereotype which impacts your medical
decision-making.
• i.e.A missed diagnosis of hepatitis in an alcoholic with liver
failure.

31. This occurs by favoring data that
correlates with a less severe diagnosis.
• i.e. Benign prostatic hypertrophy versus prostate
cancer.
It is human nature to prefer a more
pleasant clinical outcome.

32. Physicians have a tendency toward
action rather than inaction.
At times inaction is most prudent.
• i.e.Fever of unknown origin.
All actions have consequences which
must be considered in treating a patient.

33. Confirmation bias
• Selectively looking for data that will confirm your
diagnosis.
Anchoring
• Linear thinking in collecting data that will support
your diagnosis, meanwhile ignoring possibly
contradictory testing.

34. This is the tendency to stop looking for a
diagnosis once you have found one.
• If treatment fails, what diagnoses may have missed?
• What other diseases may have a similar
presentation?

35. A pre-existing diagnosis is
commonly accepted as correct.
• To avoid this error, consider the primary data
correlating with the patient diagnosis.

36. ▪ Aggregate bias
▪ Ambiguity effect
▪ Ascertainment bias
▪ Availability bias
▪ Base rate neglect
▪ Belief bias
▪ Blindspot bias
▪ Omission bias
▪ Feedback sanction
▪ Gambler’s fallacy
▪ Hindsight bias
▪ Information bias
▪ Order effect
▪ Playing the odds
▪ Posterior probability error
▪ Premature closure
▪ Representativeness restraint
▪ Sunk cost fallacy
▪ Sutton’s slip
▪ Triage cueing
▪ Ying yang bias
▪ Zebra Retreat

37. A good patient history
is the key to every
patient encounter.
Physical exam and
diagnostic testing
helps to confirm your
primary diagnosis and
rule out other potential
causes.

38. Systematic approach
- Good habits will help prevent important details
from being missed.
- A systematic approach is especially important
in medical training.

39. An effective differential diagnosis and
management plan help protect against:
• Confirmation bias
• Anchoring
• Satisfaction of search

40. The true art of medicine involves
dealing with uncertainty.
All actions in medicine is based
on the patient history which is
flawed by opinion and subjective
reasoning.

41. Disease management is not a simple
and definitive process but rather is a
process of dealing with uncertainty.
• How do we truly know our diagnosis is correct?

42. When faced with uncertainty, various subconscious
mechanisms are used to provide reassurance.
• Overconfidence occurs in an attempt to meet assumed
expectations.
• Confirmation bias and anchoring provide false reassurance.

43. Inadequate patient history
Current body of knowledge is simply inadequate.
Inadequate medical knowledge
• This is a more common issue in general practice.

44. The most important aspect of
treating a disease is the patient.
Each patient is unique and
different.
Effectively dealing with
uncertainty requires treating
each patient, not simply
treating a disease.

45. Disease management needs to be
consistent with patient expectations.
• i.e. Cancer therapy. What are the treatment goals of
a patient with advanced breast cancer? Is the
patient looking for a cure or comfort?
• Keep in mind all actions have consequences.

46. A second point to keep in mind is that
human physiology is unique to each patient.
• Human physiology does not follow strict logic.
• Successful treatment in one patient may not correlate
with success in another patient.
• If a treatment fails, be cautious to rethink your treatment
and diagnosis.

47. Each patient is unique. This relates to both
disease response to therapy and patient
expectations.
Always treat your patient rather than simply
treating a disease.
A good history is key to an accurate diagnosis
and effective patient management.

48. Be aware of potential errors in your thinking.
Protect against cognitive errors with a thorough
history, physical exam, and a comprehensive
differential diagnosis.
Always consider life-threatening illnesses that
may correlate with the patient history.

49. ▪ Groopman, Jerome. How Doctors Think. NewYork: Mariner Books, 2008.
▪ Tshienda M. Denon, Ahuka O. Longombe.The quinine infusion overuse in general practice,
Eastern DR Congo, Rev. Méd Gd. Lacs 2016 June ;7(2):26-2
▪ Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones
MA, Loftus S, Christensen N. Clinical reasoning in health professions. Amsterdam:
Elsevier;2008. p. 4-19.
▪ Edwards I, Jones M, Carr J, Braunack-Mayer A, Jensen GM. Clinical reasoning strategies in
physical therapy. Physical therapy. 2004;84(4):312-30.
▪ WHO. Promoting rational use of medicines, https://www.who.int/activities/promoting-
rational-use-of-medicine, accessed on May 2022
▪ Ntamabyaliro et al. Drug use in the management of uncomplicated malaria in public health
facilities in the Democratic Republic of the Congo, Malar J (2018) 17:189
https://doi.org/10.1186/s12936-018-2332-3

50. Questions