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How We Think and ….Pitfalls !
Manish Suneja, MD Scott Vogelgesang, MD
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Five Quick Questions…
Take a piece of paper and write down your answers to each of these 5 questions…
You have about 5 seconds for each response
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Question 1
How many turtle doves did my true love
send to me on the second day of Christmas?
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Question 2
In 2014 , the average time required to
complete a CBL case was 15½ hours. How much time should be allowed for the three that are expected next month?
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Question 3
A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball.
How much does the ball cost?
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Question 4
If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets?
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Question 5
In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half of the lake?
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Answers
Q1. 2 Q2. 46½ hours Q3. The ball cost 5 c and the bat $1.05 Q4. 5 minutes Q5. 47 days
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Cognitive Reflective Test
Disregard the first 2 questions The remaining 3 questions are simple but people
perform poorly The test distinguishes intuitive from analytical
reasoning It tests the ability to resist first response that comes
to mind Of 3,428 people tested, only 17% got all 3 correct 33% answered all 3 incorrectly
Shane Fredrick
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Session Objectives….
Introduce dual process reasoning
Understand some of the cognitive biases in clinical practice
Recognize the importance of de-biasing strategies
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Clinical Reasoning…
It is the process by which we arrive at a diagnosis: problem solving or searching for a solution
Understanding this process can help
identify our shortcomings…help us get better at this process
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We have a new way of looking at how clinicians reason...
It can be applied to all decision making in clinical care
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Unconscious
Conscious
Rapid
Intuition
System 1
Deliberate
Metacognition
System 2
Quirk, M 2006; Croskerry, 2009
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Two basic types of reasoning...
Type 1 (intuitive) and
Type 2 (analytical) (dual process theory)
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System 1: Intuition
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System 1: trust sense of familiarity
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System 2: Metacognition
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System 2: Think it through, then decide
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Operating characteristics of the model
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Two Process Model of Decision Making
Expert
Novice Expert
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4 Main Features of the Model
Repetitive operation of Type 2 Type 1 Type 1 override of Type 2 dysrationalia
override Type 2 override of Type 1 rational
override Your brain likes to take the easy way out
(cognitive miser function)
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Patient example…
Pt presents to the ER with shortness of breath, hypoxia (low oxygen levels in blood), chest pain, tachycardia (pulse rate of 120) and long flight from Japan...
Dx of pulmonary embolism immediately
comes to mind……. Type 1 reasoning Mental shortcut...
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Two Process Model of Decision Making
Expert
Novice Expert
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Rational Override… You want to jump to a diagnosis…pulmonary
embolism but you don’t... Type 2 analytical response in this case might
be to consider other possibilities like heart failure, pneumonia, asthmas, etc…
Acts likes an executive control over Type 1 Strong in people who are careful, prudent
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Swallowing saliva…
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Would you drink a glass of your own saliva?
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The emotion of disgust (Type 1) overcomes rational input (Type 2), a
form of dysrationalia override
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System 1: Intuition
PITFALLS
Strongly influenced by
ambient conditions
Atypical presentations
Pattern mistaken for
something else
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System 2: Metacognition
PITFALLS
IMPRACTICAL SLOW
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Why did you miss dx past year?
A. It never crossed my mind B. Paid too much attention on
one finding C. Didn’t listen enough to
patient’s story D. Was in too much of a hurry E. Didn’t know enough about
the disease F. Let the consultant convince
me G. Didn’t reassess the situation H. Patient had too many
problems at once I. Was influenced by a ‘similar’
case J. Was in denial of an ‘upsetting’
diagnosis G Bordage, Acad Med 1999
It nev
er cro
ssed
my m
ind
Didn’t list
en en
ough t...
Didn’t kno
w enou
gh ...
Didn’t rea
sses
s the s
i...
Was in
fluen
ced by
a ‘...
10% 10% 10% 10% 10%10%10%10%10%10%
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Causes of Diagnostic Errors
Result of both cognitive errors and system
failures
Graber ML, et al. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-9.
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Cognitive Errors
1. Faulty context assumptions 2. Premature closure 3. Inherent shortcomings of heuristic (intuitive) thinking 4. Affective biases 5. Environmental factors that detract from optimal conditions: distractions, fatigue, stress, workload
Graber ML, et al. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493-9.
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Is avoiding errors/biases Mission Impossible?
Bluegreenblog 2006
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Are we all prone to these biases?
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Why do we make mistakes/errors? 1. We are humans… 1. Limitations of our experience/knowledge
2. Decisions are made with partial information
gathering problems
3. Our brains are designed to be fast, frugal, and correct most of the time (System-1)
4. Thinking (System-2) is slow and difficult, and frequently avoided; System-2 is lazy
5. Competing demands for our time and attention favors System-1 over System-2
Unwillingness to accept the possibility of error
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Cognitive Biases: Anchoring Bias
• We tend to rely too heavily on the first piece of information offered when making decisions.
• Failing to adjust this initial impression in the light of later information leads to errors.
• After arriving at a first impression, the tendency
to look for evidence that confirms the initial impression, failing to adjust the initial impression in light of all available information.
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• A 42 y/o female presents with severe abdominal pain after 2 days of binge drinking, also has severe nausea and vomiting.
• The ER physician realizes it a usual case of alcoholic pancreatitis.
• Tests for alcohol blood level. This is high. • For additional accuracy, he also orders tests for amylase,
lipase, WBC. This are also high. • Hematocrit is low, this is frequently associated with pancreatitis
and further confirms the diagnosis. • Abdominal X-ray does not show any other abnormality. • NPO is ordered as well as IV pain meds and IV fluids. • Patient is admitted to the floor and in the next 5 hours
deteriorates and becomes progressively hypotensive until losing consciousness.
• CT scan of the abdomen reveals that she has a ruptured ectopic pregnancy!
Why was the ectopic pregnancy misdiagnosed? -less suspicion for a pregnancy as patient is 42 y/o -who in their sane mind would binge drink while pregnant? -ectopic pregnancy can also present with: elevated amylase, elevated, leukocytosis, hematocrit drop, abdominal pain and vomiting.
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Cognitive Biases: Confirmation Bias
Confirmation bias: tendency to seek data to confirm (not refute) the hypothesis
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Cognitive Biases: Confirmation Bias A woman hires a worker that she thinks highly
of, but turns out to be incompetent. She doesn’t notice that everyone else is doing his work for him because she is so impressed that he shows up every day, right on time.
A sports fan who believes his team is the best
only seems to remember the matches they won and none of the embarrassing defeats to inferior opponents.
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Mr W is a 51 y/o male with a 7 day history of lower back pain after lifting a heavy box at work.
Presents to the ER complaining of a 10/10 back pain and asking for pain medications and a work excuse.
VS:150/91, HR 105, T 99.6 F, RR 16. Nurse states: Mr. W is here again, he comes frequently asking for
work excuses. He was here yesterday and was dx with a back muscle strain.
Exam: Paraspinal tenderness, neuro exam is normal. A new prescription of Percocet is written. Patient is about to be
discharged when staff physician notices the fever. He orders a CBC that shows 17 WBC.
A CT scan is done: Paraspinal abscess. (After questioning, patient admits to have recently been using IV drugs).
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Cognitive Biases: Diagnostic Momentum Bias
When suggestion gets the best of us
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Cognitive Biases: Premature Closure • Uncritical acceptance of an initial diagnosis
and failing to search for information to challenge the provisional diagnosis or to consider other diagnoses.
• Tendency to stop too soon and not order the critical test or gather the critical information.
• One of the most common sources of error. “When the diagnosis is made, the
thinking stops”
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Some other Cognitive Biases….
Availability Bias: the tendency to weigh likelihood of things by how easily they are remembered. Base Rate Neglect: tendency to ignore the true rate of disease and pursue rare, more exotic diagnoses. Representativeness: tendency to be guided by prototypical features of a disease and miss atypical variants.
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Is there any way to avoid these biases?
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Cognitive Pills for Cognitive Ill’s
• Develop Insight • you can’t fix something you are not aware exists: Metacognition • Step back from immediate problem to examine and reflect on the
thinking process
• Consider Alternatives • Routinely ask yourself “what else might this be?”: Diagnostic
Timeout Engage system 2 • Feedback
• What happened to the patient you admitted from the ER?