The impact of cognitive bias on diagnostic failure

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Timothy Shields
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1 The impact of cognitive bias on diagnostic failure Pat Croskerry MD, PhD, FRCP(Edin) Webinar Ohio Patient Safety Institute 18 July 2018

2 Emergency Care Research Institute (ECRI) 2018 list of patient safety concerns Diagnostic errors Opioid safety across the continuum of care Care coordination within a setting Workarounds Incorporating health IT into patient safety programs Management of behavioral health needs in acute care settings All-hazards emergency preparedness Device cleaning, disinfection, and sterilization Patient engagement and health literacy Leadership engagement in patient safety

3 What do we know about diagnostic errors?

4 US deaths in ,105 Heart disease 584,881 Cancer 251,454 Medical error Medical error is the 3 rd leading cause of death

5 Diagnostic failure is the biggest problem in patient safety Newman-Toker, 2017

6 Why does misdiagnosis occur?

7 Sources of Diagnostic Failure The System 25% The Individual 75% Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what s the goal? Acad Med. 2002;77:

8 Kachalla et al, (Closed malpractice claims) Annals of Emergency Medicine 2007

9 Diagnostic Failure 15%

10 It varies by specialty Dermatology Radiology (1-2%) Anatomic pathology Internal medicine Family medicine (~15%+) Emergency medicine

11 Estimates of Diagnostic Error Rate in Internal Medicine Using Different Methodologies (adapted from Graber, 2013) Research approach Patient surveys Second reviews Method Image or sample is reviewed by another clinician Observation 33% of patients relate a diagnostic error that affected themselves, a family member or close friend 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 to act as a real patient to simulate a set of symptoms or problems Internist misdiagnosed 13% of patient presenting with common conditions (chronic obstructive pulmonary disease, rheumatoid arthritis, others) Look backs Specific conditions are retroactively investigated to see if diagnosis could have been 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 changed the management found in 10-20%

12 The complexity of diagnostic reasoning

13 Sleep deprivation Fatigue Stress Intellect Ethnicity Culture Affective state Cognitive load Sleep debt System design Ergonomic factors A Knowledge Experience Religion C Team factors D Gender Age Communication Scheduling IT Personality Metacognition Critical thinking Experientiality Reflection Symptoms Onset E Pathognomonicity B Active Open-minded Thinking Rationality Reflective coping Adaptiveness Signs Progression Co-morbidities Mimics Perseverance Logicality Mindfulness Lateral thinking Need for cognition Family Friends F Patient Caregivers Other patients

14 Why haven t we heard more about this?

15 Factors that keep us in the dark Invisible process Poor feedback Physician hubris Individual denial, distancing, discounting Non-medical mechanisms Highest morbidity and mortality Litigation

16 Legal outcome by critical incident CMPA Data : 347 legal actions closed Number of patients Perform Comm Diagnosis Admin Medication Conduct

17 Legal outcome by critical incident CMPA Data : 347 legal actions closed Perform Comm Diagnosis Admin Medication Conduct

18 Legal outcome by critical incident CMPA Data : 347 legal actions closed Perform Comm Diagnosis Admin Medication Conduct

19 The IOM Quality Chasm Series

20 The most critical factor in medicine? Human bias Oct 13, 2015 Oncologist and writer Siddhartha Mukherjee suggests that what doctors fight against isn t so much disease it s their own biases. IDEAS.TED.COM Explore ideas worth spreading

21 What does decision making look like?

22 Decision Making Intuitive (System 1) Rational (System 2) Fast Informal Subjective Context-dependent Qualitative Slow Formal Objective Context-independent Quantitative

23 Dual Process Decision Making

24 Dual Process Decision Making System 1: Automatic/streamlined System 2:Cautious/complex

25 95% RECOGNIZED Type 1 Processes Patient Presentation Pattern Processor Pattern Recognition Executive override T Irrational override Calibration Diagnosis Repetition NOT RECOGNIZED Type 2 Processes 5%

27 Getting medicine is not easy

28 Decision making involves learning the basic patterns COW

29 Getting medicine is not easy

30 Getting medicine is not easy

31 Getting medicine is not easy

32 Factors that improve our decision making

33 Knowledge Rationality Critical Thinking Intellect

34 Problems with rationality

35 Rationality Failure Processing problems Content problems Cognitive miserliness Mindware gaps Mindware contamination WYSIATI Minimising cognitive effort Accepting things at face value Insufficient breadth and depth Avoiding complexity (Hasty judgments) Hasty Judgments Failures Knowledge of tools of deficits rationality Impaired Knowledge scientific deficits thinking Impaired scientific thinking Impaired probability thinking Impaired probability thinking Ignoring alternate Being illogical hypotheses Insufficient critical thinking Distorted Probability estimates Cognitive biases Cultural conditioning Illogical reasoning Egocentric thinking Biased Judgments

36 Case A 21 y/o male arrives at the ED with multiple stab wounds to the chest, arms and head. One of the chest wounds is inferior to the L scapular. OE: Talking, cooperative, inebriated, no dyspnoea or SOB, AE = bilaterally, 02 Sat N; 130/80, HR Lac on scapula deep local wound exploration did not penetrate the pleural cavity, ribs palpable with pleura behind. EDTUS: good views, no free fluid. Serial abdominal exams N, rectal exam N. CXR N. Lacerations irrigated, explored, and repaired. Discharge Dx: Stab wound chest. D/C Home 5 days later presented to a different hospital with vomiting, blurred vision and difficulty concentrating CT scan showed penetrating wound to brain

Cognitive biases Anchoring: locking onto specific features of a problem and failing to adjust to other aspects Search satisficing: after potentially most serious injury is addressed, search is called

38 Cognitive biases Anchoring: locking onto specific features of a problem and failing to adjust to other aspects Search satisficing: after potentially most serious injury is addressed, search is called off for other serious injuries. Posterior probability error: vast majority of scalp wounds previously seen have been benign and WYSIATI. Overconfidence (hubris): Resident is in year 5 Cognitive miserliness: ED is busy, fatigue, sleep deprivation, dysphoria

39 One of the major mindware contaminants is bias We need to understand characteristics of biases

40 There are lots of biases

41 The Biases Social/Cultural Affective Cognitive (Contaminated Mindware)

42 Social Biases in Medicine Race/ethnicity Gender Obesity Age Socio-Economic status Psychiatric illness Drug/alcohol dependency

43 Aggregate bias Gender bias Psych-Out Errors Anchoring Hindsight bias Representativeness Ascertainment bias Multiple alternatives Search satisficing Availability Omission bias Sutton s Slip Base rate neglect Order effects Triage-Cueing Commission bias Outcome bias Unpacking principle Confirmation bias Overconfidence Vertical line failure Diagnostic momentum Playing the odds Visceral bias Attribution error Posterior prob. Ying-Yang Out Gambler s Fallacy Premature closure Zebra retreat

45 Leaving the dark side Raise awareness of the importance of decision making Understand how dual process theory works Teach the main biases and essentials of bias mitigation Promote rationality and critical thinking Raise awareness of conditions which may compromise decision making (fatigue, sleep deprivation, cognitive overload)

46 High Risk Situations o Cognitive overloading o Fatigue o Sleep deprivation/sleep debt o Negative mood o Alcohol/drug influence

47 Cognitive Debiasing Strategies Teach the basic rationale: DPT and where errors are Review the main cognitive and affective biases Teach specific strategies for particular biases Forcing functions consider alternatives Encourage decision maker to get more information - unpack Be alert for atypical presentations Encourage metacognition and reflection Slow down Minimize time pressures don t be rushed Think the opposite Maintain a healthy skepticism about intuitions Share decision making when possible think out loud Use memory aides: checklists, algorithms, medical apps, CDRs, practice guidelines Educate intuition Promote less hubris, less overconfidence

49 core-units/dme/critical-thinking.html

Dual Process Theory. Conference for General Practice 2013 Generalism: The heart of health care Jeff Brown

Dual Process Theory. Conference for General Practice 2013 Generalism: The heart of health care Jeff Brown Dual Process Theory Conference for General Practice 2013 Generalism: The heart of health care Jeff Brown Pat Croskerry Critical thinking and healthcare safety Distinguishes intuitive from analytical processing