How Providers think Cognition in medicine. Disclosure. Outline. I have nothing to disclose. Dennis J. Boyle, MD COPIC Denver Health/UCSOM 2010

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1 2006 Wotkyns Creative How Providers think Cognition in medicine Dennis J. Boyle, MD COPIC Denver Health/UCSOM 2010 Disclosure I have nothing to disclose 2 Outline Two brains How we decide Cognitive theory How we think as docs The fix 3

2 4 Paul Simon When I look back at all the crap I learned in high school, it s a wonder I can think at all Kodachrome 1973 Computer brain vs. emotional brain 5 Three history taking and decision styles Left brained Right brained Pattern recognition 6

3 7 Left brained Controlled Rational Closed ended questions High control style Classic ROS Right brained Open questions Creative Allows patient to tell a story Allows to build connection Allows for the 2 CC s 8 Pattern recognition Limbic system Intuitive Gut instincts Where heuristics occur 9

4 10 The battle of the brain 11 Prefrontal cortex The executive Regulates emotion Integrates info Source of great solutions 12

5 13 Brilliant thinking UAL 232 Cerebral cortex no answer Emotions swirl-shut them down with the prefrontal cortex Prefrontal cortex comes up with differential thrust 14 Orbital frontal cortex Lies between what we see/ hear/feel and think Decision making and sensory integration Iowa gambling test 15

6 16 Anterior cingulate cortex A collar around CC Lies between what we see/ hear/feel and think Emotional control Learnable moments Right and wrong error detection/oh sh..! 17 Blink 18

7 19 Simple vs. complex decisions 20 Expert thinkers Cognition is how people reason and make decisions Providers may use deduction, induction or intuition to solve problems Novices lean toward deduction and exhaustive W/U Experts have more knowledge and use logic, probability and especially intuition Coderre Med Ed

8 22 Cognitive theory - Deductive reasoning Goes from the general to the specific Top down - Formulate a short list, examine, test, DX All turtles have shells Coma in ER- AEIOU TIPS Aristotle 23 Cognitive theory - Inductive reasoning Not always correct but used by experts Gravity All swans I ve seen are white Sir Francis Bacon

9 25 Heuristics Heuristics are shortcuts in reasoning More inductive than deductive Use verbal and nonverbal clues to allow DX in 30 seconds The basis of a quick brilliant DX but can be wrong The common error is premature closure Most biases lead to anchoring Lock in DX too early Crosskerry story Cure is to reconsider when new data appears and ask what would I hate to miss? 26 Anchoring bias The best and brightest missed the DX on the president s wife. Ouch! 27

10 28 Anchoring bias Anchoring bias 29 Anchoring bias 30

11 31 Availability bias DX by what you ve seen most recently or what comes to mind the easiest Verify with stats If you hear hoof beats. Framing bias Subtle words influence decision Lung CA surgery 58% vs 75% Pt has CP and ETOH on his breath. Feelings color our thinking Cure - lets play the devil s advocate Mcneil NEJM Affection bias A doctor who treats himself has a fool for a patient Patients swim together with physicians in a sea of feelings Groopman How Doctors Think 33

12 34 Quote Our propensity for certain types of errors is the price we pay for our brain s ability to think intuitively Reason 1993 Bayes theory Apriori probability changing with each new SX Many of us use Bayesian reasoning Great for probability but is limited by patients unique illness and inability to deal with complex prediction 35 Bayes theory let s suppose 1% of women age 40 have Breast CA 80% with Breast Ca pts have positive mammographs 10% w/o CA have positive tests If test is positive what s the chance it s CA? 36

13 37 What s the chance it s cancer? 8% 32% 48% 80% We re bad at probability estimates 8% 38 ROWS In the ER always R/O the worst case scenario 50% of ER visits result in no definite DX Croskerry 39

14 40 Bottom line ROWS Our task is not to attain certainty but to reduce uncertainty enough to make therapeutic decisions Kassier 1993 Sutton s law Why do you rob banks? Because that s where the money is. Made up by a reporter Results in Sutton s slip- Maissoneuve Fracture 41 Occam s razor Entia non sunt multiplicanda praeter necessataum Law of parsimony in science When there are two possibilities chose the simplest And don t forget Hickam s dictum 42

15 43 Meta-cognition The ability to be aware of what and how one is thinking Crystal ball technique Graber Acad Med 2002 Temporal Arteritis A story 44 Temporal Arteritis A story A hospitalist calls about a 56 Y/O female with R eye vision blurring HX of DM and HTN, vague leg weakness ESR = 56 He feels 70% chance of TA 45

16 46 Temporal Arteritis My heuristic TA is less than 10% chance Pt too young ESR too low Vision loss not typical Temporal Arteritis More info Eye loss gradual and seems like vision blurred Mild frontal HA Leg weakness seems neuropathy R eye shows severe DM changes NSR and no bruits 47 Temporal Arteritis Diff DX 1) Eye disease - Lots of retinopathy, typical story 2) CVA - 4+ risks, no bruits, leg weakness not CVA 3) Doubt TA other explanations, vision loss atypical, ESR low, no PMR 48

17 49 Temporal Arteritis Diff DX 1) Eye disease - Lots of retinopathy, typical story 2) CVA - 4+ risks, no bruits, leg weakness not CVA 3) Doubt TA other explanations, vision loss atypical, ESR low, no PMR Ophthalmology consult- DM disease no AION Meta-cognition on the TA case 1 A few key findings 2 Heuristics pattern recognition 3 Collect more info prove or disprove DX 4 Diff DX apply probability estimate 5 Am I missing anything? 50 A combo of styles work the best 1 For history start with open questions 2 Then Limbic lobe with Heuristics 3 Then left brain WHAT AM I MISSING? 4 Embrace uncertainty 5 Resort to reasoning 51

18 52 Final quote Errors in judgment must occur in the practice of an art which consists largely of balancing probabilities. Medicine is a science of uncertainity and an art of probability. Sir William Osler The rubber hits the road The problem is not knowledge but thinking. Can you think of a time when you anchored too soon? Please fill out the feedback form 1 ERS point Dennis Boyle M.D. dboyle@copic.com 3 great references How we Decide How Doctors Think Acad Emer Med Croskerry