臨床推論の脳と心.pptx

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1 ICU 2015/03/17

2 A CV HP h(p://

4 gap!!

6 " Bayes Theorem Kassirer JP et al. Learning Clinical Reasoning. Lippinco( Williams & Wilkins 2009

7 1. 4 # (heuristic) # (context)

8 Heuristic \hyu - ris-tik\ using experience to learn and improve representative heuristic ex. available heuristic ex. NMDA Kahneman D et al. Judgement under Uncertainty: HeurisNcs and Biases. New York: Cambridge University Press; 1982

9 Context \ kän- tekst\ the situation in which something happens : the group of conditions that exist where and when something happens ( problem space ) Keren G. On the importance of iennfying the correct problem space. CogniNon. 1984;16:

10 The magic number 7±2 George A Miller ( ) 認知心理学者人間が認知して処理記憶できる短期記憶の量には限界がある 7 不思議 7つの海 7つの大罪プレイアデスの7 姉妹人生の7 段階 (シェイクスピアお気に召すまま ) 地獄の7 層 (ダンテ神曲 ) 7 原色 7 音 / 音階 7 日 / 週人間が短期記憶で扱えるのも7つまでなのかもしれない Psychol Rev. 1956;63(2): Available in h(p:// Behav Brain Sci Feb;24(1): The magical number 4 in short- term memory: a reconsideranon of mental storage capacity. Cowan N. (1) 情報量が多いと刺激 ( 入力 )を制限する (2) 他の作業が刺激 ( 入力 )を記録することを邪魔をする (3) 作業が容量制限によって中断される (4) その他いろいろな容量制限の間接的な影響同時に扱える診断仮説は

11 2. アクセス (confirmation strategy) (elimination strategy) (discrimination strategy) # (heuristic) #

12 physical symbol system hypothesis = 情報は記号 (symbol)として蓄積される Norman G et al. Non- analyncal models of clinical reasoning: The role of experience. Med Educ. 2007;41:

13 (prototype) (exemplar) Norman G et al. Non- analyncal models of clinical reasoning: The role of experience. Med Educ. 2007;41: Bordage G. Prototypes and semannc qualifiers: From past to present. Med Educ. 2007;41:

14 Michelene T.H. Chi et al. CategorizaNon and representanon of physics problems by experts and novices. Cogn Sci. 1981;5:87-177

16 Tulving, E. Episodic and semannc memory. In Tulving, E., & Donaldson, W. (Eds.) (1972). OrganizaNon of Memory. New York: Academic Press. Available in: h(p://alicekim.ca/tulving/ 症例スクリプト長期記憶 (エピソード記憶 ) 取り出すのに時間はかかる疾患や症候群の特徴をより多く知っている多様性も知っている体験があるコンテクスト病態生理学 Kuipers B et al. Causal reasoning in medicine: Analysis of a protocol. CogniNve Science. 1984;8:

17 3.

18 Thomas Bayes ( ) Bayes theorem Richard Price Essay Philosophical Transactions of the Royal Society of London 53 (1763),

19 1 B A P(A B) = P(A) P(B A) = P(B) P(A B) ( ) = P B A P(A B) P(A)

20 2 Ai B A = Ai i=1 P(B) = P(B i=1 = P( i=1 n i=1 n Ai ) n i=1 n (B Ai )) = P(B A i ) = P(B A i )P(A i )

21 A 1, A 2,..., A n P(A k B) = P(A k B) = P(B) P(A k )P(B A k ) n i=1 P(A i )P(B A i )

22 / /6

24 1 1 θ (α, β) β p(zθ) = θ x i (1 θ) n β w(θ) θ α 1 (1 θ) β B(α,β) = w(θ)dθ =1 1 0 u α 1 (1 θ) β 1 du x i

25 w'(θ z) w(θ) p(zθ) w'(θ z) θ α $ 1 (1 θ) β $ 1 α " = α + x i, β " = β + n α, β θ E(θ) = α α + β x i

26 E "(θ) = α " α " + β " α " = 4, β " =1

27 2

29 pretest Odds = a + c b + d posttest Odds = a b = a + c b + d = pretest Odds sensitivity 1 specificity a(b + d) (a + c)b a b c d = pretest Odds positive likelihood ratio

30 簡略化のために発熱の事後確率は省略 Clinical Infectious Diseases 2007; 45:55 9 Odds = p 1 p = = 0.052

31 JAMA. 2006;296(16): Odds = p 1 p positivelr = = 0.79 posttest Odds = 1+ posttest Odds = 0.44

32 3 ICU

34 p log( 1 p ) = β + β x + β x + β x 0 1 age 2 male 3 weight p(y =1x age = i +1) 1 p(y =1x age = i +1) p(y =1x age = i) 1 p(y =1x age = i) p 1 p = exp(β 0 + β 1 x age + β 2 x male + β 3 x weight ) [ ] [ ] = exp β + β (i +1) + β x + β x male 3 weight exp β 0 + β 1 i + β 2 x male + β 3 x weight = exp(β 1 )

36 4. Hume 先行する事象がなければ存在し得ない事象が経時的に後に続くこと Susser CausaNon. J. Philos 1970: あらゆる要素出来事特徴など定義できるもので健康状態を改善するか悪化させるかいずれかの変化をもたらすものは原因となりうる Causal Thinking in the Health Sciences: Concepts and Strategies of Epidemiology. New York; Oxford University Press, 1973!!!

37 Hill s criteria ( ) 1) 2) 3) 4) 5) 6) 7) 8) 9) Proceedings of the Royal Society of Medicine, 58 (1965),

38 5. Parsimony: Ockham s razor Falsification:

39 " Bayes Theorem

40 parallel computer HeurisNcな仮説の生成膨大なScriptの照会ベイジアンでの事後確率 P(A k B) = P(A k B) P(B) = P(A k )P(B A k ) n i=1 P(A i )P(B A i ) Connectionism Parallel distributed processing Pessoa L et al. Top-Down Mechanisms for Working Memory and Attentional Processes. In: The Cognitive Neurosciences. 3 rd ed. MIT Press; 2004:

41 診断を検証する診断仮説がうまれる因果推論を使う診断仮説をくり返し見直す検査を使う

42 Goal-directed strategy ex. Data-driven strategy ex. Day1 Kassirer JP et al. Learning Clinical Reasoning. Lippinco( Williams & Wilkins 2009

43 Premature closure

44 Premature closure Croskerry P. The importance of cogninve errors in diagnosis and strategies to minimize them. Acad Med. 2003;78: