Post on 18-Dec-2021
10/4/2016
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Diagnostic Error: Overview, Challenges and Recommendations
John Banja, PhDCenter For EthicsEmory University
jbanja@emory.edu
• “When you think about it, clinical reasoning is probably the most important thing a doctor does.”
–Pat Croskerry, MD, PhD
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Leon Festinger: Cognitive Dissonance• CD is an
uncomfortable feeling caused by holding two contradictory ideas simultaneously;
• What happens when a very deep-seated belief is disconfirmed by new data?
The Encounter With Uncertainty in a Clinical Context
• Behavioral: Stymied, paralyzed, incapacitated, unable to move forward;
• Cognitive: Cannot assign outcome probabilities confidently; cannot plan or envision a course of action or a treatment plan;
• Affective: Anxiety, feeling lost, helpless, disoriented, etc.
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The Story
• Mrs. Keech and her religious group believe the world will end (by flood) Dec. 21, 1954 per a message Mrs. Keech received from the planet Clarion
• The group leaves their jobs, college and spouses, they give away their money and possessions.
They await a flying saucer, which will save them and take them to Clarion at midnight
• 12:05 AM, Dec. 21: No visitor. The group agrees their clock is fast by 10 minutes.
• 12:10 AM: No visitor.
• 4:00 AM: No visitor. Mrs. Keech begins to weep.
• 4:45 AM: Mrs. Keechreceives a message from Clarion.
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The Message
• God has decided to spare the planet from destruction; the cataclysm has been called off
•Why?
Because “The little group, sitting…
all night long, had spread so much light that God had saved the world from destruction.”
• Mrs. Keech: “At no time has there been such a force loosed upon the Earth. Not since the beginning of time upon this Earth has there been such a force of Good and light as now floods this room.”
Mrs. Keech and her group had
saved the world!
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Fundamental Beliefs are …
• Our “STAYIN’ ALIVE” navigational tools
• Make meaning and sense of our experiences and the world
• Provide the most basic and fundamental directions for our beliefs, feelings, and behaviors
THEY ARE PROFOUNDLY SELF-DEFINING!
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And this is the SelfProfessionals Want to Preserve
PROFESSIONAL
SELF
Adequate
Competent
Useful
Informed In control
Assured Powerful
Awesome
But this professional self is under constant attack!
The Remarkably Imperfect Human Being
• Human cognition is re-markably fallible: slips, lapses, mistakes, unintentional as well as intentional variations of standard processes, faulty reasoning, prone to implementing biases (e.g., availability, confirmation, anchoring, etc.) leading to error, etc.
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Add to that the Degraded Work Environment
Work area design
Faulty communication
New or unfamiliar procedures
Multi-tasking
Shift work fatigue
Constant interruptions
Phone calls
Pre-occupation
Need to hurry
Long waits to be seen
Dim lighting
Noise
Many sick patients
Home stress
Uncertain expectations
Violence
Short-staffed
Multi-tasking
Technology won’t work
Ambiguity
New trainees
Hunger
Taking short cuts
Conflicting priorities
Unworkable policies
And not only that but……
• Unpredictable and dynamic environments• Multiple sources of concurrent information (with
varying accuracies)• Reliance on indirect or inferred indications (e.g.,
judgment calls)• Actions having multiple consequences• High stress• Complex human to machine interfaces• Multiple players with varying levels of
competence and familiarity• High stakes that may compromise risk awareness
and risk aversiveness
Complex systems are intrinsically hazardous
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Catastrophe is always a possibility …
Complex systems possess potential for catastrophic failure. Human practitioners are nearly always in close physical and temporal proximity to these potential failures…It is impossible to eliminate the potential for such catastrophic failure; the potential for such failure is always present by the system’s own nature.
Complex systems are heavily defended against failure
People create safety
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Uncertainty
The diagnostic pieces don’t fit together
Leon Festinger: Cognitive Dissonance• CD is an
uncomfortable feeling caused by holding two contradictory ideas simultaneously;
• What happens when a very deep-seated belief is disconfirmed by new data?
Antidote: Overconfidence• “Overconfidence results at
times from a desire to see the self as a competent or accurate perceiver…undue confidence often arises when uncertainty would challenge valued beliefs about the self as knowledgeable and competent…the motive to see the self as competent leads to less critical analyses of the true ability levels during confidence assessments…our participants were motivated to protect themselves from the implications of feeling uncertain.” (Blanton, 2001)
• “Most efforts to reduce overconfidence have failed.” (Arkes, 1987)
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More problems• “The more
knowledgeable I feel myself to be, the less I use a decisional aid.”
• “The more I know, the more I realize how much I don’t know; the less I know, the more I think I know.” Lesson: Learn more! Never stop!
Need to feel adequate and competent
Call upon usually reliable diagnostic heuristics
The inevitable encounter with Uncertainty
Psychological Response: Overconfidence
No or Poor (Systemic) Feedback
(“a culture’s tolerating suboptimal performance”? Graber et al, 2005)
Improving Diagnostic Accuracy and Clinical Reasoning
“Fallibility is the human condition.”
Robert Miles, MD
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What probably doesn’t work• Generic CME courses:
These lectures probably don’t change behavior (which presumably is what characterizes learning); however, focused, disease/diagnostic specific courses or lectures probably do;
• Urging practitioners to be more careful
Metacognition (Bounded rationality) challenges and strategies
• “The first step is to overcome the bias against overcoming bias.” (Croskerry)
• Biases can only be offset with System 2 reasoning• Capacity for self-critique:
– Recognition of memory limitations– Recognizing biases
• Search satisficing• Availability and confirmation • Prototype and assumption• Appreciating my perspectivalism
– Force consideration of alternatives (e.g., insist on the acquisition of more data)
Might technology save us?
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The Electronic Health Record?• Technology might organize and
“trend” a patient’s medical history better; the problem now is that you have too much data;
• List differential diagnoses• Collect records• Maintain patient history• Maintains problem lists and
tracks medications and tests• Provides feedback to upstream
clinicians• Provides prompts (diagnostic
thoroughness)• Calculates Bayesian probabilities• Offers second opinion or
consultation through telephone access to consultants (Shiff and Bates, NEJM, March 25, 2010)
More
• Teaching a course in clinical reasoning
• Simulations
• Deliberate disengagement from System 1 approaches, which is very difficult to do: you have to train yourself to do it
• Seeking others’ opinions
• Lower the threat in admitting a lack of knowledge
Reducing Overconfidence:“Most efforts to reduce overconfidence have
failed.”• “You should only be as
confident as you are accurate.”
• Pay more attention to disconfirming evidence
• Accept the discomfort of uncertainty
• Make errors more visible (which can be humiliating)
• Make cognitive support more accessible, e.g., technology, consults, etc.
• (Gamblers become more confident after they place their bets.)
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Better Feedback
• Must not be judgmental• Have accurate data and evidence• Contains concrete information
that is performance—not attitudinally—oriented;
• Focused on behavior• Demonstrates correct behavior• Respectful of recipient’s self-
esteem• Negative feedback is
“sandwiched” between positive information
• Allow for response and interaction
• No inflammatory or threatening language
• Solicit learner’s response often
• Focus on behavior and insure learner understands the point
• Establish mutually agreed upon goals
• Remember sandwich technique!
Sibinga and WU on Mindfulness(JAMA, Dec. 8, 2010)
Being Mindful• Care based on clinician blaming
patient or patient behavior
• Physician’s affect influences interpretation
• Focus on most typical features of the symptom presentation (representative bias)
• Makes judgment that most easily comes to mind (Availability)
• Focuses on limited aspects of the patient’s symptoms (representativeness)
• Only admits information that fits the favored conclusion (confirmatory)
• TRUST
• NONJUDGING
• ACCEPTANCE
• LETTING GO
• NONSTRIVING –PATIENCE
• OPENNESS
• HUMILITY
• LISTENING
• COMPASSION
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Including the patient/family in the diagnostic process
• Frame diagnosis as hypothesis
• Encourage access to medical record
• Greater transparency
• Develop familial communication skill set
Production Pressures
• Can clinicians take back the authority to say to administrators “What you want me to do/How you want me to work isn’t safe”?
• Import more technology—replace humans with machines
Humility Strategies
• “…openness toward reflection that would allow for better toleration of uncertainty… making error visible…provide expert consultations.” (Berner, 2008)
• “[T]he motive to boost confidence may be attenuated if a person is first given opportunities to lower the importance of feeling knowledgeable.” (Blanton, 2001)
• “[O]ur participants were motivated to protect themselves from the implications of feeling uncertain...one of the best ways to decrease overconfidence may be to decrease the threat inherent in admitting ignorance.” (Blanton, 2001)
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The problem with the last slide is it contradicts the biographical histories of most physicians
• You didn’t get into medical school by making mistakes
• Mistakes were the bad guys; you stopped making them in high school.
• You grew pathologically averse to error
• You became compulsive and loathed error
Change the psychological environment of diagnostic decision making to something kinder, humbler, and more realistic given human and system limitations
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