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Dual Process and Cognitive Bias in Clinical Decision Making
Joan M. Von Feldt, MD, MSEdProfessor of Medicine
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Thinking Fast and SlowDaniel Kahneman
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Heuristics and Biases
Thin Slicing
RecognitionPrimed
Deliberationwithout attention
Modularresponsivity
Gestalt effect
Inductivereasoning
Hypothetico-deductivereasoning
RobustDecisionMaking
Normativereasoning
ExhaustionStrategy
Boundedrationality
Bayesianreasoning
Approaches to Decision Making
Intuitive Analytical
Croskerry. Adv in Health Sci Ed 2009; 14:27-35
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System I (Intuitive)
System II(Analytical)
Cognitive Style Heuristic Systematic
Cognitive Awareness Low High
Automaticity High Low
Rate Fast Slow
Effort Low High
Emotional Component High Low
Scientific Rigor Low High
Errors More Less
Properties of the 2 types of decision-making
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Examples: System 1 & 2 Thinking
Your route to work
An out of town guest staying with you who
will meet you at your work
Your route to work after being away for 20
years or major road work
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Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35.
Model for diagnostic reasoning based on pattern recognition and dual-process theory
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Heuristics
Pattern Recognition Illness Scripts Gestalt Instance Scripts i.e “Blink”; “Thinking Fast”
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Heuristics
Can be good: » provide cognitive “short cuts” in the face of complex
situations» Help us to be efficient
Can be bad:» They tend to be thinking traps – so beware!» Can adversely influence our diagnostic decisions
Croskerry, P. Acad Med 2003; 78:775-80.
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Institute of Medicine Report Published in 1999
Addressed the problem of preventable medical errors
Charged the healthcare industry to evaluate and change their systems to prevent patient harm
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Systems Errors: Complicated
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Cognitive Errors: Just As Complicated…But In A Different Way
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Cognitive Error Categories
Faulty Knowledge
Faulty Data Gathering
Faulty Information Processing
Faulty Verification
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Origins of diagnostic error in 100 patients
Leape LL, et al. N Engl J Med 1991; 324(6): 377-84.
Graber ML. Franklin N. Gordon R. Diagnostic error in internal medicine. Archives of Internal Medicine, 2005; 165(13): 1493-9.
19% related to Systems
Error28% related to Cognitive
Error46% related
to both Systems and Cognitive
Errors
Forgot to f/u on the blood cultures…
Poor communication among consultants…..
Didn’t expand your differential diagnosis…..
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Anchoring Bias
Also called “premature closure”
the failure to continue considering reasonable alternatives after a primary diagnosis is reached, is the most common diagnostic error
ie When the diagnosis is made, the thinking stops
Croskerry, P. Acad Med 2003; 78:775-80.
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Confirmation Bias
Confirmation bias
Tendency to look for confirming evidence to support a diagnosis rather than look for discomfirming evidence to refute it (despite the latter often being more persuasive and definitive)
Absolutely!
Croskerry, P. Acad Med 2003; 78:775-80.
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Availability
Availability bias
Judge things as being more likely if they readily come to mind
Croskerry, P. Acad Med 2003; 78:775-80.
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Unpacking Principle
The failure to elicit all relevant information in establishing a differential diagnosis that may result in significant possibilities being missed
Croskerry, P. Acad Med 2003; 78:775-80.
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Framing Effect
The framing of the patient scenario, including the source and where the patient is seen, influences the way the patient is thought about
Croskerry, P. Acad Med 2003; 78:775-80
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Diagnosis Momentum
Also known as “chart-lore”- once diagnostic labels are attached to patients, they become stickier and stickier
Croskerry, P. Acad Med 2003; 78:775-80.
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Visceral Bias
Counter-transference negative feelings towards a
patient may result in diagnoses being missed
Common Types» Non-compliant patients» Homeless patients» Patients with chronic pain» Obese patients
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Cognitive Bias Can Lead to Errors in Diagnosis
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How Do We Deconstruct Our “Brick Walls”?
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5 Basic Questions to Help Avoid Cognitive Errors
What are traps I might fall into
What else can it be?
Is there anything that doesn’t fit?
Is there’s more than one thing going on?
Is this a case where I need to “slow down”?
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Summary
Heuristics are important for efficiency of care Heuristics can also be used for expediency of care
that may compromise optimum care Cognitive bias is an important factor that can
adversely influence diagnostics Thorough problem lists and broad differentials can
mitigate some cognitive bias MD 305 rule: Minimum of 3 diagnoses, 2 organ
systems
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