10/4/2016

1

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

10/4/2016

2

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.

10/4/2016

3

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.

10/4/2016

4

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!

10/4/2016

5

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!

10/4/2016

6

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.

10/4/2016

7

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

10/4/2016

8

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

10/4/2016

9

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)

10/4/2016

10

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

10/4/2016

11

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?

10/4/2016

12

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.)

10/4/2016

13

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

10/4/2016

14

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)

10/4/2016

15

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

10/4/2016

16