Biases and debiasing

Pat Croskerry MD, PhD

The Biases

AffectiveAffective

CognitiveCognitive

Social/Social/CulturalCultural

Affective BiasAffective Bias

• When the affective state of the decision maker adversely When the affective state of the decision maker adversely affects decision makingaffects decision making

• Due to a failure in rational/logical decision makingDue to a failure in rational/logical decision making• Usually due to ‘hot emotion’ (vivid-tepid continuum)Usually due to ‘hot emotion’ (vivid-tepid continuum)• There are about 20 known affective biasesThere are about 20 known affective biases

– UniversalUniversal– PredictablePredictable– Correctable (affective de-biasing)Correctable (affective de-biasing)

HOTHOT COOLCOOL

The Emotional SpectrumThe Emotional Spectrum

Cognitive and affective debiasing

Four major issuesFour major issues

• Getting people to recognize there is a problem• Accepting that change must occur• Choosing an appropriate debiasing strategy• Teaching and sustaining debiasing strategies

Many clinicians are Many clinicians are unaware of the problem…unaware of the problem…

And some people will never And some people will never change…change…

So how do we become So how do we become better decision makersbetter decision makers

??

REMEMBERREMEMBER

Most of our biases live in the intuitive Most of our biases live in the intuitive mode (System 1)mode (System 1)

The most important step is The most important step is de-coupling from System 1de-coupling from System 1

Pattern Recognition

Repetition

Executiveoverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

Type11

Processes

Type22

Processes

T

ExecutivExecutiv

e e overrideoverride

•Thinking about how we think• Reflection• Mindfulness• Metacognition• System 2 monitoring of System 1

• System 2 modulation of System 1

• Cognitive decoupling from System 1

• Cognitive debiasing

We need to We need to maintain maintain

a feral vigilancea feral vigilance to detect biaseto detect biasess

It ain’t It ain’t easyeasy

• Even though bias detectedEven though bias detected• Very unlikely one strategy works for allVery unlikely one strategy works for all• Need for multiple approachesNeed for multiple approaches• Very unlikely one shot will workVery unlikely one shot will work• Need for multiple innoculationsNeed for multiple innoculations• Need for extra vigilance in critical conditionsNeed for extra vigilance in critical conditions• Need for lifelong maintenanceNeed for lifelong maintenance

Issues that impedeIssues that impede cognitive and affective de- cognitive and affective de-

biasinbiasing

VariableVariable DescriptorDescriptor

Clinical relevance Cognition has not been seen as the business of medicine. Cognitive processes are not usually studied by clinicians except in disease states such as brain injury, dementia, autism and others.

Lack of awareness Many clinicians are naïve about cognitive processes and unaware that cognitive and affective biases may significantly impair clinical judgment. Usually, not covered in medical undergraduate or postgraduate training.

Invulnerability to cognitive and affective error

Some clinicians may be aware of cognitive and affective biases but do not believe that they are vulnerable to them (cognitive egocentrism, optimism bias, blind spot bias) or that they might affect their own practice.

Myside bias If clinicians (and researchers) believe cognitive and affective bias are unimportant in clinical reasoning, they will have a prevailing tendency to evaluate data, evidence, and hypotheses in a manner supportive of their opinions.

Status quo bias Cognitive de-biasing requires Type 2 processing and significant cognitive effort. It is considerably easier to continue with the status quo, rather than make the effort to learn a new approach and change current practice.

Belief perseverance The human tendency is to bolstering existent beliefs rather than searching for new approaches. Established beliefs are remarkably resilient. Despite evidence that contradicts or discredits a belief, we may continue to hold it.

Overconfidence Clinicians’ overconfidence in their own judgments may be the most powerful factors that contribute to diagnostic failure. Hubris and lack of intellectual humility characterize the uncritical thinker.

Vivid-pallid dimension Discussions of cognitive processes per se are dry, abstract and uninteresting to the medical mind. They typically lack the vividness and concrete nature of clinical disease presentations that are more appealing to clinicians.

What strategies do we have for debiasing?

Cognitive Debiasing StrategiesCognitive Debiasing Strategies Teach the basic rationale: DPT and where errors areTeach the basic rationale: DPT and where errors are Review the main cognitive and affective biasesReview the main cognitive and affective biases Teach specific strategies for particular biasesTeach specific strategies for particular biases Forcing functionsForcing functions Encourage decision maker to get more informationEncourage decision maker to get more information Encourage metacognition and reflectionEncourage metacognition and reflection Slow downSlow down Think the oppositeThink the opposite Maintain a healthy skepticismMaintain a healthy skepticism Group decision makingGroup decision making Educating intuitionEducating intuition Less hubris, less overconfidenceLess hubris, less overconfidence

High Risk SituatioHigh Risk Situations

• Cognitive overloadingCognitive overloading• FatigueFatigue• Sleep deprivation/sleep Sleep deprivation/sleep debtdebt• Negative mood/affective Negative mood/affective statestate• Alcohol/drug influenceAlcohol/drug influence

• Is this patient handed off to me from a previous shift     Diagnosis momentum, framing                

• Was the diagnosis suggested to me by the patient, Premature closure, framing

       nurse or another MD ? 

• Did I just accept the first diagnosis that came Anchoring, availability, search satisficing, to mind ? premature closure    

• Did I consider other organ systems besides the                Anchoring, search satisficing, premature closure

obvious one?

• Is this a patient I don’t like for some reason ?                  Affective bias

• Was I interrupted/distracted excessively while All biases

evaluating this patient?            

• Did I sleep poorly last night? All biases

• Am I feeling fatigued right now?    All biases                      

• Am I cognitively overloaded or                                All biases over-extended right now?

• Am I stereotyping this patient?                                         Representative bias, affective bias, anchoring, fundamental attribution error

• Have I effectively ruled out must-not-miss diagnoses?   Anchoring, overconfidence, confirmation bias

                                   

High risk situations

The Ultimate Debiasing Strategy?

What else could What else could this be?this be?