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Korzybski, Hayakawa, Lao Tsu and Your Patient

Mark A. Graber, MD MSHCE FACEP Professor of Family and Emergency Medicine University of Iowa Carver College of Medicine

Goals •  Discuss some cognitive errors and how to

avoid them. •  Discuss some aspects of General

Semantics and how they apply to medicine

Why this is important. •  We spend our working hours using:

– Language – Logic

•  We should be pretty good at it.

Every decision bases itself on something not mastered, something conceled or confusing.

Martin Heidegger

Principle 1: Diagnosis and Treatment are Probabilistic and Not Absolute.

There are false positives and false negatives.

Put Another Way… There is no certainty, only progressively more convincing evidence.

A physicist who’s name I forget

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Or... There is no such thing as absolute certainty, but there is assurance sufficient for the purposes of human life.

John Stuart Mill

Never tell someone they have appendicitis until you have surgical

confirmation.

There are degrees of disease Wrong Questions

•  Does the patient have hypertension or not? –  Is it really going to make a difference if I go from 141/90 to

139/89??

•  Did I meet his cholesterol (or blood sugar) goal? –  Is it really going to make a difference if I get to 129mg/dl from

131mg/dl cholesterol? –  Is it really going to make a difference if I get from 7.0 HbA1c to

6.9 HbA1c?

Principle 2: Never Believe the Patient’s Diagnosis: Form your own

Differential Diagnosis

Principle 3: Don’t assume you and the patient are speaking the same

language.

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The one word, one meaning fallacy

•  Just because two things have the same name doesn’t mean they are the same. –  “Chest pain” –  “Dizzy”, “the flu”, etc. –  “Worst pain imaginable” –  “Trouble Breathing”

Principle 4: If things don’t fit, change your model.

Piaget Theory of Adaptation •  Assimilation:

– Use existing scheme to interpret data. –  Information distorted to fit preconceived

notion. – Child and dog, student and infiltrate.

•  Accommodation: Alter existing scheme or create new one in response to new information

Anchoring bias – locking on to a diagnosis too early and failing to adjust

to new information.

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Confirmation bias! we tend to ignore information that doesn’t conform to our

hypothesis. We don’t try to prove ourselves wrong.

Change your model instead.

Next

The greatest barrier to the proper diagnosis is a prior diagnosis.

J. Hoffman

Never Believe the Chart You may be a better clinician than

the last provider.

Types of Cognitive Error •  Diagnosis momentum – accepting a

previous diagnosis without sufficient skepticism.

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Diagnosis momentum •  Patient seen with headache and facial

pain. Initial diagnosis of sinusitis. Seen several providers over several weeks. Eventual diagnosis brain tumor.

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Un-sanity •  Reacting to new or changing situation as if

it were the old situation. •  Doing the same thing over and over again

and expecting a different result.

Un-Sanity contd. •  How many courses of antibiotics is this for

sinusitis? •  How many anti-migraine drugs have failed? •  And remember, the greatest barrier to the proper

diagnosis is a prior diagnosis….

Come up with a list of 10 things your patient can have.

If you don’t think about it you will never find it.

•  Diagnosaurus!Free on AccessMedicine

•  Isabela •  Check Lists •  Check the app store

Principle 5:The words that you use to describe something changes how you

feel about it.

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Connotations vs. Denotations •  Judgments •  (connotation) She is faking!! He is non-compliant!!

•  Reports (denotation)

She has a somatization disorder. He has not been able to follow my instructions because……

How does language change your feeling/approach?

•  It is 3:00 am. You are tired. Your are called to see a 79 year old nursing home patient with dementia who is wheel chair bound and has a fever.

•  It is 3:00 am. You are tired. You are called to see a gray haired, “grandmotherly” type who, at the age of 79, is somewhat forgetful and needs some assistance preparing meals and getting around. She has a fever from an unknown source.

Examples: The nurse tells you the patient is a:

•  Crock •  Frequent Flyer •  Drug Seeker •  Crank •  Nuts

Principle #6: Over reliance on experience leads to making the same

mistakes with greater confidence.

Author Unknown

Types of Cognitive Error •  Overconfidence bias – Over-reliance on

one’s own ability, intuition, and judgment.

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Is does not imply ought. David Hume

Just because this is the way it has always been done does not mean

that is the correct thing to do.

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Principle 7: Don’t react to symbols. Symbol versus Signal Reaction

What a “real doctor” looks like Which one is the provider?

Studies have shown that: •  How the patient dresses affects whether

we believe them or not. •  Something as simple as having

“somatization disorder” or “depression” written on the chart changes our estimate of disease probability.

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So you think you aren’t affected by symbol reactions?

Used under GNU license

Also known as: •  Attribution error: Negative stereotypes

lead clinicians to ignore or minimize the possibility of serious disease.

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“Somebody do something”…. The world is ruled by letting things take their course. It can not be ruled by interfering.

Lao Tsu

. •  Do nothing which

is of no use. – Miyamoto

Musashi

Association doesn’t equal causality

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Types of Cognitive Error •  Availability bias – thinking that a similar

recent presentation is happening in the present situation.

•  “Rule of 3s” •  Missed a PE? You will be more likely to

check a CT scan in a low risk patient. 49

Types of Cognitive Error •  Premature closure – similar to

“confirmation bias” but more “jumping to a conclusion”

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Types of Cognitive Error •  Search-satisfying bias – The “eureka”

moment that stops all further thought.

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Search-satisfying bias •  45 year old lady, abdomen pain and

bloating. Recent work stress. Blood tests: FBC ESR Celiac antibodies. Normal diagnosis of IBS, in fact CA Ovary

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Representation Error •  Representation error: When you hear

hoofbeats think horses, not zebras. •  Take into account prior probability of

disease.

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Affective Error •  Affective error involves avoiding

unpleasant but necessary tests or examinations because of fondness or sympathy for the patient

•  This is why I hate taking care of colleagues.

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Minimizing cognitive errors •  If it is not the working diagnosis, what else could

it be?

•  What are the most dangerous things it could be?

•  Is there any evidence that is at odds with the working diagnosis?

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Metacognition Simply being aware of they types of errors can help prevent them.

Finally….Bambi vs. Godzilla Any Questions?