Thinking About How to Think: A Clinician’s Approach to...

Thinking About How to Think: A Clinician’s Approach to

Decision Making Dr Cherie-Lee Adams

FRCPC Emergency Medicine Assistant Professor, Dept of EM, Dalhousie University Attending EM Physician, Saint John Regional Hospital

Ed Rounds 12 May 2015

Objectives

• To review the prevalence and clinical significance of good clinical decision making. ie: the evidence

• To review common types of bias in clinical practice.

• To explore the dual-process model of clinical decision making.

• To discuss approaches to limit diagnostic bias in clinical practice.

• To discuss an approach to impart good clinical reasoning skills to learners.

Why this?

Hysteria or Evidence-based?

• Study 1

• ~30 000 charts of NY state inpatients

• 3.7% rate of adverse events

• 27.6 % ‘negligence’

• 2.6%- permanent disability

• 13.6% death!

Brennan, Leape, Laird et al (1991)NEJM 324(6):370-5

Specialities at Greatest Risk?


Populations at Greatest Risk


Hysteria or Evidence-based?

• Study 2

• sub analysis of AEs identified in Study 1

• 48% AEs surgically related

• 19% drug related

• Negligence:

• 37% of non-surgical AEs

• 75% diagnostic error

• 70% of AEs occuring in the EDLeape, Brennan, Laird et al. (1991) NEJM 324(6):377-84

And in ‘The True North’?

• 3745 charts from a hospitals in 5 provinces

• academic, community, rural

• AEs in 7.5%, 37% ‘preventable’

• 5.2% permanent disability; 20.8% death!

• older patients more affected

Baker, Norton, Flintoff et al. (2004) CMAJ 170(11):1678-86

The What and The Where

Baker, Norton, Flintoff et al. (2004) CMAJ 170(11):1678-86

Categorizing Diagnostic Error

• Knowledge inadequacy

• Information Gathering

• Information Processing

System Errors

• Technical

• lab error

• lack of access

• Organizational

• inaccessibility to expertise

• process inefficiency

• policy failure Graber, Gordon, Franklin (2002) Acad Med. 77(10):981-92

No Fault

• atypical/silent presentation

• ↓patient cooperation

• undescribed condition

Cognitive

What’s the Problem

• ~8000 charts from Dutch acute care admissions & deaths

• 0.4% of all admissions found to have DAE

• 83% of DAEs deemed preventable

• DAEs most common (75%) in non-surgical populations

• 96% DAEs associated with failed cognition

Zwaan, Bruijne,Wagner, et al (2010)Arch Intern Med. 2010;170(12):1015-1021

Where does Cognition Fail?

• 100 cases of diagnostic error causing injury

• 46% attributable to cognitive failure sub-analyzed

• 83% of cognitive errors are in information synthesis

Graber, Franklin, Gordon (2005)Arch Intern Med.165(12):1493-99

33%

50%

14%3%

KnowledgeInfo GatheringProcessingVerification

Failure in information:

Recap

• AEs are:• prevalent

• preventable.

• procedural & drug-related > diagnostic

• DAEs are caused by failed cognitive processing.

Decision-making Theory: Dual process Model

Patient Presentation

Modified from: Croskerry (2009) Acad Med. 84:1022-8

Recognized

Novel

System 1

System 2

Diagnosis




Recognized

Novel System 2

Diagnosis

System 1:“intuitive”

• fast• autonomous• unconscious




Recognized

Novel

Diagnosis

System 1:

System 2:“analytic”

• slow• deliberate

• rational/logical




Recognized

Novel

System 1

System 2

Diagnosisrepetition

Potential Biases

• aggregate bias

• anchoring

• ascertainment

• availability

• base-rate neglect

• commission

• confirmation

• diagnostic momentum

• feedback sanction

• framing effect

• fundamental attribution error

• gamblers’ fallacy

• posterior probability

• gender

• hindsight

• multiple alternatives

• omission

• order effects

• outcome

• overconfidence

• representativeness

• search-satisfying

• Sutton’s slip

• Sunk costs

• Triage cuing

• Unpacking

• Vertical line

• Visceral

• Yin-yang out

Croskerry (2003) Acad Med 78(8):775-80

Factors Promoting Bias

• fatigue, circadian disruption

• patient vol, acuity

• multitasking, interruptions

• training, experience

• cognitive overloading

• low signal-noise ratio

• volume/acuity

• frequent diagnostic uncertainty

• ergonomics, layout

• overcrowding

• noise

• limited resources

Individual Acute Care Environment

Croskerry (2014) CJEM 16(1):13-19

The Evidence: System 1 Performance

• 75 mid-level postgraduates

• assigned diagnoses to 25 computer-based cases

• Correlation of Time vs Accuracy = -0.54

• System 1=accurate?

Sherbino, Dore, Wood et al (2012) Acad Med 87(6):785-91

The Evidence: System 1 Performance

• 96 PGY2 residents

• assigned diagnoses to 20 computer-based cases

• randomized • be quick & accurate (S1)

• careful, thorough, reflective (S2)

• Overall accuracy 44.5% vs 45%

• Time to diagnosis: 69s vs 89s p<0.001

• Taking time is not enough!

Norman, Sherbino, Dore, et al (2014)Acad Med. 89(2): 277-84

Recap• Limiting diagnostic error is important.

• Dx error is caused by failed cognitive processing.

• System 1 is pretty good, though potential landmines (bias) exist.

• Slowing down doesn’t remove the landmines.




Recognized

Novel

System 1

System 2

Diagnosisrepetition




Recognized

Novel

System 1

System 2

Diagnosisrepetition?

strategies to limit bias• Cognitive ‘hygiene’

• Cognitive debiasing• cognitive unloading

• metacognition

• cognitive forcing strategies

• Feedback• incident reports

• M&M’s

• consultation notes

• autopsy/coroner reports

• Education• simulation

• address sp bias/strategy

Croskerry (2003) Acad Med 78(8):775-80

Cognitive Hygiene

• Optimize your environment• advocate for ergonomics,

functional layout

• foster positive team interactions

• foster a culture of decreasing unnecessary interruptions

• minimize white noise

• Efficiently attend to To Do’s

• Optimize yourself• limit fatigue

• attempt to maintain circadian rhythm/reset physiologically

• maintain good diet, exercise

• maintain vigilance re: bias

Landmine Identification: Metacognition

• Awareness of the process

• Recognition of the limitation of memory

• Ability to appreciate perspective

• Capacity for self-critique

• Ability to select strategies

‘thinking about thinking’

Croskerry, Singhal, Mamede (2013) BMJ Qual Saf. 22(ii):58-64

Cognitive unloading

• limit reliance on memory

• examples:

• mnemonics

• algorithms

• CDRs

• CPGs

• point-of-care access to evidence

Cognitive Forcing Strategies

• “a deliberate, conscious selection of a particular strategy in a specific situation to optimize decision-making and avoid error.”

• examples:

• cardinal rules’, caveats, checklists, differential lists, decision aids

Croskerry, Singhal, Mamede (2013) BMJ Qual Saf. 22(ii):58-64

CFSs: Checklists

• Diagnostic Pause:

• Have I been complete?

• Are there any biases to consider?

• Is this the best time to make a dx?

• Have I considered the worst-case scenario?

Ely, Graber & Croskerry (2011) Acad Med 86(3):307-13

Is CFS Instruction Effective?• n=191 CC3 randomized

• CFS orientation vs self-directed study time

• tested after 4w ED rotation

• no difference in exp/control wrt• search satisfying bias-prone cases

• availability bias-prone cases

• Conclusions??• control not effectively isolated fr tested biases • uptake >4w

• junior learners using system 2 • CFSs don’t work

Sherbino, Kulasegaram, Howey et al (2014) CJEM 16(1):34-40

Teaching Good Cognition:

Teaching Good Cognition?

• ACTAM• Applied Cognitive Training in Acute-Care Medicine

• introduced pre-clerkship

• series of 12 clinical cases followed by commentary highlighting cognitive error

• glossary of terms

• MCQ self-test Croskerry, P. (2006) ACTAM Manual: A Cognitive Analysis of Clinical Cases

Dalhousie University: Intoduction to Clerkship 2006


• 48 PGY2 GIM residents, Pennsylvania

• Longitudinal program:

Reilly, Ogdie, von Feldt et al (2013) BMJ Qual Saf 22:1044-50

• Pre-post program assessment

• 21% (of 48 PGY2’s) lost to follow up?!

• novel MCQ tool

• Results

• 1pt improvement over pre-program

• 2pt improvement over PGY3 control

• other descriptive results unconvincing


What now?

• Teaching strategies exist

• Good assessment tool needed

• validation• other programs

• other populations

• look to the horizon?

Teaching Good Cognition:

Take-Home Points• Medical error is prevalent and largely preventable.

• Complex systems govern the breadth of medical error, but diagnostic error is particularly relevant to front-line clinicians.

• Diagnostic error results from failed cognitive processing.

• An ongoing, multi-pronged approach may help to mitigate bias, but remains to be proven.

• Strategies exist to teach learners cognitive debiasing techniques, but their efficacy remains unproven.

Thank You- Questions?

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