Teaching the Scarecrow: Improving Thinking to Improve ... · 3/18/2019 1 Teaching the Scarecrow:...

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Teaching the Scarecrow: Improving Thinking to Improve Clinical

Decision Making

Pat Croskerry MD, PhD, FRCP(Edin)

27th Annual Rural and Remote Medicine Course

Halifax Convention Centre April 4-6 2019

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Does decision making actually need improvement?

Most of us do not reach our potential for critical thinking

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Decision making

‘The most important decision we need to

make in Life is how we are going to make

decisions’

Professor Gigerenzer

3 domains of decision making

Patients

Healthcare leadership

Healthcare providers

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Patients

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Leading Medical Causes of Death in the US and their Preventability in 2000

Cause Total Preventability(%)

Heart disease 710,760 46

Malignant neoplasms 553,091 66

Cerebrovascular 167,661 43

Chronic respiratory 122,009 76

Accidents 97,900 44

Diabetes mellitus 69,301 33

Acute respiratory 65,313 23

Suicide 29,350 100

Chronic Liver disease 26,552 75

Hypertension/renal 12,228 68

Assault (homicide) 16,765 100

All other 391,904 14

Keeney (2008)

Healthcare leadership

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Campbell et al, 2017

Healthcare providers

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US deaths in 2013

• 611,105 Heart disease

• 584,881 Cancer

• 251,454 Medical error

Medical error is the 3rd leading cause of death

Makary and Daniel, BMJ 2016

Data source: Xu et al, 2016 NVSS

(National Vital Statistics System)

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Estimated number of preventable hospital deaths due to diagnostic

failure annually in the US

40,000 – 80,000

Leape, Berwick and Bates JAMA 2002

Sources of Diagnostic Failure

Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what’s the goal?

Acad Med. 2002

The Individual75%

The System25%

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Diagnostic failure is the biggest problem in

patient safety

Newman-Toker, 2017

Many physicians are reluctant to believe this

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Diagnostic Failure

15%

It varies by specialty

DermatologyRadiology (1-2%)Anatomic pathology

Internal medicineFamily medicine (~15%+)Emergency medicine

Rural and remote medicine (?)

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Researchapproach

Method Observation

Patient surveys 33% of patients relate a diagnostic error that affectedthemselves, a family member or close friend

Second reviews Image or sample is reviewed by anotherclinician

10-30% of breast cancers are missed on mammography;1-2% of cancers misread on biopsy samples

Standard patients Clinician is unaware that patient is trained toact as a real patient to simulate a set ofsymptoms or problems

Internist misdiagnosed 13% of patient presenting withcommon conditions (chronic obstructive pulmonarydisease, rheumatoid arthritis, others)

Look backs Specific conditions are retroactivelyinvestigated to see if diagnosis could havebeen made at an earlier stage

30% of subarachnoid hemorrhage misdiagnosed;39% of dissecting abdominal aortic aneurysm;Delayed diagnosis; 25-50% of women with cervical cancer– last PAP abnormal on re-read

Autopsies Major unexpected discrepancies that would have changedthe management found in 10-20%

Estimates of Diagnostic Error Rate in Internal Medicine UsingDifferent Methodologies (adapted from Graber, 2013)

Diagnosis is the canary in the coal mine for decision failure

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How well do doctors think?

Kachalla et al, Annals of Emergency Medicine 2007

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Legal outcome by critical incident

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40

80

120

160

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240

Perform Comm Diagnosis Admin Medication Conduct

CMPA Data : 347 legal actions closed 2005 - 2009

Number of patients


0

40

80

120

160

200

240



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The complexity of diagnostic reasoning

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Gender

Ethnicity

Perseverance

Mindfulness

Reflection

Age

Intellect ActiveOpen-minded

Culture Critical thinkingRationality

Adaptiveness

Experience

Experientiality

Need for cognition

Personality

LogicalityMetacognition

Reflectivecoping

BA

C

Fatigue Cognitive load

Sleep deprivation

Sleep debtStress

Affectivestate

Teamfactors

Lateral thinking

Religion

Knowledge

D

System design

IT

Communication

Scheduling

E

Symptoms Signs

Pathognomonicity

Co-morbidities

Progression

F

Patient

Family

Friends

CaregiversOnset

Ergonomic factors

MimicsHealthcare settingOther Patients

Features of rural and remote medicinethat may impact decision making

Wider scope of practice

Access to specialists

Access to resources

Work longer hours

Higher Doctor : Patient ratio

Social proximity of patients

Zebra retreat

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Understanding decision making

Dual Process Theory

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Decision Making

Intuitive (System 1)

Rational(System 2)

Fast Informal

SubjectiveContext-dependent

QualitativeFlexible

SlowFormal

ObjectiveContext-independent

QuantitativeRigourous

Dual Process Decision Making

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Dual Process Decision Making

System 1: Automatic/streamlined System 2:Cautious/complex

A schematic model of how the systems work together

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Pattern Recognition

Repetition

Executiveoverride

Irrationaloverride Calibration Diagnosis

PatientPresentation

RECOGNIZED

NOTRECOGNIZED

Type1

Processes

Type2

Processes

TPattern

Processor

95%95%

5%

Clinicalproblemfeatures

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

AdvancedBeginner

Proficiency

RoutineExpertise

Competence

Type2

Processes

Type1

Process

Novice

A B

MindwareGap

RationalityCritical thinking

Metacognitive processesLateral thinking

Flexibility, creativity, innovation

Type2

Processes

Type1

Process

Proficiency

Competence

AdvancedBeginner

Novice

RoutineExpertise

AdaptiveExpertise

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Critical thinkingMetacognitive processes

Rationality, biases. mitigation Lateral thinking

Humanities

Mindware Gap

The best calibrated decisions are described as

‘rational’ – they come from a blend of System 1 and

System 2 decisions

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What is meant by rationality?

The best possible decision given the available evidence and the prevailing conditions

Assuming you are well-slept, well-rested, well-fed, and can give the problem your undivided attention

And you are aware of and know how to deal with bias

RationalityFailure

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Processing problems Content problems

RationalityFailure

Processing problems

Cognitive miserliness

RationalityFailure

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Processing problems


WYSIATIMinimising cognitive effort

Accepting things at face valueInsufficient breadth and depth

Avoiding complexity

RationalityFailure

Processing problems




Avoiding complexity

Hasty Judgments

RationalityFailure

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Avoiding complexity

Hasty Judgments

RationalityFailure

Mindware

The software of the brain

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Mindware gaps




Avoiding complexity

Hasty Judgments

RationalityFailure


Mindware gaps




Avoiding complexity

Failures of tools of rationalityKnowledge deficits

Impaired scientific thinkingImpaired probability thinking

Being illogical

Knowledge deficitsImpaired scientific thinking

Impaired probability thinkingIgnoring alternate hypotheses

Hasty Judgments

RationalityFailure

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Mindware gaps




Avoiding complexity



Being illogical



Hasty Judgments Distorted Probability estimates

RationalityFailure


Mindwarecontamination

Mindware gaps




Avoiding complexity



Being illogical



Distorted Probability estimates

Hasty Judgments

RationalityFailure

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Mindware gaps




Avoiding complexity



Being illogical



Cognitive biasesCultural conditioning

Illogical reasoningEgocentric thinking

(Hasty judgments)Hasty Judgments Distorted Probability estimates

RationalityFailure



Mindware gaps




Avoiding complexity



Being illogical



Cognitive biasesCultural conditioning

Illogical reasoningEgocentric thinking

(Hasty judgments)Hasty Judgments Distorted Probability estimates

Biased Judgments

RationalityFailure

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Ambient Dx Risk Situations

• Cognitive overloading

• Interruptions/distractions

• Sleep deprivation/sleep debt

• Negative mood

• Fatigue

So how do we help scarecrows?

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You aren’t thinking critically enough, so try harder

Is trying harder going to work?

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The occasional slap might wake some people up

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Main Points

The barometer for failed clinical reasoning is diagnostic failure

The current estimate of diagnostic failure is 10-15%

The sources of diagnostic failure are System (25%) and Individual (75%)

The principle source of individual failure is how the individual thinks and less what they know

The main factor that determines thinking competence is rationality

We need to promote facilitators of rationality

Scarecrow Imperatives

• Raise awareness of the importance of decision making• Promote metacognition, reflective practice, mindfulness• Teach the main biases and essentials of bias mitigation• Raise awareness of conditions which may compromise decision

making (fatigue, sleep deprivation, cognitive overload)• Promote rationality, critical thinking, and lateral thinking• Promote adaptive decision making and resilience• Promote the humanities!

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No longer an option…

Summary

• Improving rationality improves decision making

• It can be taught

• Training should be explicit (not implicit or tacit)

• Current medical training may suppress it?

• It is needed in UGME, PGME, and CME

• It is an ethical imperative

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Thank you

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Rationality of clinical decisions

Patientpreferences

KnowledgeComprehensionAccessibilityReliability

UnderstandingDual Process

Understandingcognitive andaffective bias

+ logical fallacies

CBMmindwareavailable

MetacognitionMindfulnessReflection

Dalhousie model of cognitive processes and clinical decision making

Patientpresentation

Communication issues

Rationality Ordering andinterpretation of appropriate investigations

ClarityPrecisionAccuracySignificanceRelevance

CompletenessLogicFairnessBreadthDepth

Critical Thinking Standards

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Teaching the Scarecrow: Improving Thinking to Improve ... · 3/18/2019 1 Teaching the Scarecrow:...

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