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 Tests ability to resist first response that comes to mind Of 3428 tested only 17% got all 3 correct 33% answered all three incorrectly Frederick 2002 (MIT)
Intuitive fast automatic thinking Analytical slow deliberative thinking
Decision Making Intuitive (System 1) Rational (System 2) Fast Informal Subjective Context-dependent Qualitative Flexible Slow Formal Objective Context-independent Quantitative Rigourous
System 1 vs System 2 disposition Clinical inertia Thematic vagabonding Goal fixation Failure to engage feedforward control Encysting (paralysis by analysis) Indolence
Biostatistics Contingency tables Sensitivity and specificity Bayes theorem Type 1 and Type 2 error Randomisation Intention to treat Confidence intervals, odds ratios Reviews, meta-analysis Publication bias, citation bias Decision theory and analysis
Comfortable numbness of living in intuitive mode Critical thinking depends on resisting the first response that comes to mind
Can educate and train intuition Can develop forcing functions Can teach, train and improve performance in analytical mode Promote reflective practice Promote use of cognitive aids eg clinical decision rules
1. Unreflective thinker 2. Challenged thinker 3. Beginning thinker 4. Practising thinker 5. Advanced thinker 6. Accomplished thinker
Awareness of determining role of thinking and that problems can lead to serious outcomes Recognises that thinking is flawed but unable to identify the factors that cause it Rudimentary grasp of standards (clarity, accuracy, precision, relevance, logicalness) and how to attain them Limited skills but often overconfident in abilities Lack of intellectual humility Needs a framework for understanding how thinking works and the factors that influence it
Knowledge of standards (clarity, accuracy, relevance, logicalness) Awareness of need to internalise standards Ability to monitor and take active control of thinking processes Ability to recognise distracting stimuli, propaganda, irrelevance Ability to recognise eccentric and sociocentric thinking Intellectual humility Knowledge of main cognitive/affective biases and logical fallacies Able to identify, analyse, and challenge assumptions in arguments Ability to recognise deception, deliberate or otherwise Capability to assess credibility of information Ability to imagine and explore alternatives Understanding of how to effectively work through problems Capacity for making effective decisions Awareness of value of practice and training of critical thinking skills Understanding of continuing need to maintain good thinking habits
1. Unreflective thinker 2. Challenged thinker 3. Beginning thinker 4. Practising thinker 5. Advanced thinker 6. Accomplished thinker It s not what we don t know, it s how we think
2005 2006
2011
Diagnostic Failure Missed diagnosis Delayed diagnosis Wrong diagnosis
Netherlands 2004 7926 records from 40 hospitals Diagnostic errors mostly PE, sepsis, MI, appendicitis Human cognitive factors in 96% of DAEs System failures in 25% of DAEs Zwann et al, Arch Int Med, 2010
Legal outcome by critical incident: CMPA 347 legal actions 2005-2009 240 200 160 120 80 40 0 Perform Comm Diagnosis Admin Medication Conduct
USA malpractice claims 350 706 paid claims 1986-2010 Diagnostic errors 28.6% Treatment injury 27.2%, Surgery 24.2% Leading cause of death 40.9% vs 23.9% Permanent disability just as likely as death More outpatient 68.8% than inpatient 31.2% Cost $38.8 billion Failure to diagnose 54.2%, delay 19.9%, wrong 9.9% Tehrani et al, BMJ Qual Saf, 22 April 2013
That quietly occur in clinician s minds are the most common, most costly and most dangerous of medical mistakes (among malpractice claims) Unattainable perfection is no excuse for inaction We re not doing the best we can Consider diagnostic safety a critical health policy issue Focus our energies on errors that lead to the greatest patient harm Newman-Toker, BMJ Qual Saf, 22 April 2013
Do you believe that on their social media profiles, other people make themselves look happier, more attractive and more successful than they really are? YES 76% NO 17% Time/ABT SBRI Poll, 20 June 2013
Do you believe your social media profile reflects what you are really like? YES 76% NO 17% Time/ABT SBRI Poll, 20 June 2013
Across all medical disciplines Factors leading to error No fault 7% System related only 19% Cognitive error only 28% Combined 46%
40 hours for most skills or pattern recognition Send system 2 into system 1 Toggle function Executive override (2 over 1) Dysrationalia override (1 over 2) Brain tries to default to system 1
X4 C2 C3 C1 X4 X3 X2 X1
RECOGNIZED Intuition Patient Presentation Pattern Processor Pattern Recognition Executive override T Dysrationalia override Calibration Diagnosis Repetition NOT RECOGNIZED Analytical
RECOGNIZED System 1 Expertise Proficiency Initial percept or problem Pattern Processor Competence Calibration Decision Advanced Beginner Novice NOT RECOGNIZED System 2
Axial view of fmri activation of the brain as a function of practice over 60 minutes Hill and Schneider, 2006
Toggle Function Hypothesis Hopping RECOGNIZED Intuition Patient Presentation Pattern Processor Pattern Recognition Executive override T Dysrationalia override Calibration Diagnosis Repetition NOT RECOGNIZED Analytical
Hard wiring Ambient conditions/context Task characteristics Age and Experience Affective state Gender Personality RECOGNIZED Intuition Patient Presentation Pattern Processor Pattern Recognition Executive override T Dysrationalia override Calibration Diagnosis Repetition NOT RECOGNIZED Analysis Education Training Critical thinking Logical competence Rationality Feedback Intellectual ability
Toggle function Most errors occur in System 1 Repetitive operations of System 2 >>> 1 System 2 override of System 1 System 1 override of System 2 Cognitive Miser function
Most errors occur in system 1 Especially if conditions allow or enable Cognitive and affective biases Tiredness, stress, cognitive overload, age
Raise awareness of importance of decision making Know dual process approach Educate and train intuition Develop cognitive forcing strategies Promote reflective practice Teach main affective and cognitive biases Promote critical thinking Promote use of cognitive aids Teach de-biasing strategies Raise awareness of conditions that may affect
About 20 affective biases Over 100 cognitive biases Social biases Most live in the intuitive mode We spend 95% of our cognitive time there -> problem
Ambient induced Transitory states Environmental, ergonomic Stress, fatigue, sleep deprivation, cognitive overload Clinical situation induced Counter transference Fundamental attribution error Specific affective biases Endogenous Circadian, infradian, seasonal Mood, anxiety, mental illness
Universal, predictable, correctable Examples: Search satisficing call off search once something found Sutton s slip going for where the money is Triage cueing geography is destiny Anchoring Representativeness look for disease profiles Psych-out Social biases Racial, gender, obesity, ageism, etc
Getting people to recognise there is a problem Accepting that change must occur Choosing an appropriate debiasing strategy Teaching and sustaining cognitive debiasing strategies
Universal: Critical thinking training Dual process theory training Cognitive/affective bias training
Generic: Structured data acquisition Get more information Be more sceptical Slow down/reflection Rule out worst case scenario Consider the opposite
Specific: Bias inoculation strategies Re-biasing strategy Forcing functions Stopping rules Checklists
RECOGNIZED Type 1 Processes Hard-Wired Processes Emotional Processes Over- Learned Processes Patient Presentation Pattern Processor Implicitly Learned Processes Calibration Diagnosis
You will make the same foolish mistakes you have made before, not only once but many, many times again
Comfortable numbness of living in intuitive mode Critical thinking depends on resisting the first response that comes to mind