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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?
Brennan, Leape, Laird et al (1991)NEJM 324(6):370-5
Populations at Greatest Risk
Brennan, Leape, Laird et al (1991)NEJM 324(6):370-5
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
Decision-making Theory: Dual process Model
Patient Presentation
Modified from: Croskerry (2009) Acad Med. 84:1022-8
Recognized
Novel System 2
Diagnosis
System 1:“intuitive”
• fast• autonomous• unconscious
Decision-making Theory: Dual process Model
Patient Presentation
Modified from: Croskerry (2009) Acad Med. 84:1022-8
Recognized
Novel
Diagnosis
System 1:
System 2:“analytic”
• slow• deliberate
• rational/logical
Decision-making Theory: Dual process Model
Patient Presentation
Modified from: Croskerry (2009) Acad Med. 84:1022-8
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.
Decision-making Theory: Dual process Model
Patient Presentation
Modified from: Croskerry (2009) Acad Med. 84:1022-8
Recognized
Novel
System 1
System 2
Diagnosisrepetition
Decision-making Theory: Dual process Model
Patient Presentation
Modified from: Croskerry (2009) Acad Med. 84:1022-8
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
Teaching Good Cognition?
• 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
Teaching Good Cognition?
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?