Understanding How We Are Wired and Explaining Why We Short Circuit:

A Workshop in Medical Decision Making and Error

Emily Ruedinger, MD University of Washington

Andrew Olson, MD

University of Minnesota

Maren Olson, MD, MPH University of Minnesota

Emily Borman-Shoap, MD University of Minnesota

Disclosure

• None of the presenters have any relevant conflicts of interest

• But we do all have experience making errors.

• This work is supported by a Clinical Innovations Award from the AAMC

Schedule

• 2:00-2:30: Introduction

• 2:30-3:00: Small Group Case Discussion

• 3:00-3:30: Large Group Debrief

• 3:30-4:00: Implementation/Q&A

All men make mistakes…

- Winston Churchill

It is the nature of medicine that you are

gonna screw up.

- Dr. House

creativecommons.org/licenses/by-nc-sa/2.0/

All men make mistakes…

…but only wise men learn from their mistakes.

-Winston Churchill

Objectives

By the end of the workshops, attendees will: • Gain the knowledge needed to help trainees reflect

on their own decision making and identify cognitive errors

• Practice reviewing clinical experiences in which diagnostic errors occurred and trial techniques to help trainees collaboratively identify strategies to avoid these errors.

• Develop the skills to promote trainees’ involvement in constructive, non-judgmental feedback when an error occurs.

Curriculum Overview

• Series of 5 modules focused on teaching concepts of medical decision making and diagnostic error to residents

• We conducted sessions during 3 block education sessions.

• Modules adaptable to 60-90 minutes and single or contiguous sessions.

Modules

Module 1: Introduction to Medical Decision-Making and Diagnostic Error Module 2: Faculty Panel Discussion about Diagnostic Error Module 3: Case Studies in Diagnostic Error Module 4: Personal and Small Group Reflection on Diagnostic Error Module 5: Feedback Training- How to Discuss Diagnostic Error with Colleagues

Let’s start with an example

A I3 C 12 I3 14 Ann

approached the bank.

You made a choice

but didn’t know it

Image retrived on 31Oct2014 from: https://www.flickr.com/photos/frosch50/14918770014/in/photolist-oJjAyE-eWuKqB-fF3USJ-nojk2G-frnrgV-9jUgw7-hSotFA-azQDSa-fbuCv9-h6yodi-nDmXPb-fvyxkm-ntPSq1-6SHqu1-gSNm9a-9pbx2i-nwXBch-eS7wQV-mTSDjr-f3LvGM-cHqmeo-nxixzv-514qBV-fBf1RX-fG117a-bn6xge-n42iez-bDTQAB-kB8TCg-ahRkyL-fF3WxE-fSfM5c-88ZggE-62aLHE-jACgcQ-J7y6F-fA2Mia-k2Nuaa-mRNisn-hAPAMT-9v7FUg-eTz1hS-jDXD6F-8ZMjnZ-atmnDa-iPwU34-FgLJd-fZ59PV-9mAAqx-f6d6FqCreative Commons License associated: https://creativecommons.org/licenses/by/2.0/

Heuristics

Automatic shortcuts we use in response to familiar scenarios

(Think about the last time you went to work)

The Two System Model

System 1 (“Fast”)

Non-Analytic Decision Making

• Not conscious

• Automatic

• Unavoidable

• Efficient

• Make life possible

• Acquired, not learned

System 2 (“Slow”)

Analytical Thinking

• Conscious

• Effortful

• Deliberate

• Makes life possible

• Learned processes

• Not the default

Pneumonia

Bronchiolitis

Kartagener Syndrome

Reflect on the ways you see your learners practicing diagnostic reasoning: When to they practice System 1 (non-analytic, fast) decision making? When do they practice System 2 (analytic, slow) thinking? When is this appropriate or inappropriate?

Cognitive Biases

When the diagnosis is made, the thinking stops Premature Closure

Locking into salient features of a patients’ initial presentation and failing to adjust your impression in light of later information

Anchoring Bias

Judging things as more likely if they readily come to mind Availability

How we see things is strongly influenced by the way a problem is framed.

Framing Effect

Statistics presented about surgical treatment for lung cancer

“1 month survival rate = 90%”

“10% mortality in the first month”

84% chose surgery

50% chose surgery

Once a diagnostic label is attached to a patient, it becomes stickier and sticker.

Diagnostic Momentum

Emotional responses, stereotypes, assumptions

Visceral Biases

Deferring to an “authority” and following along without

thinking for oneself or challenging the authority

Blind Obedience

Think about a case that didn’t go well. What biases were at play?

• Premature Closure

• Anchoring Bias

• Availability

• Framing

• Diagnostic momentum

• Visceral Bias

• Blind obedience

HTTPS://WWW.YOUTUBE.COM/WATCH?V=YNSJAF8NON0

Diagnostic errors: “any mistake or failure in the diagnostic process leading to an incorrect diagnosis, a missed diagnosis or delayed diagnosis.” Overdiagnosis in an asymptomatic patient

Reilly JB, Ogdie AR, Von Feldt JM, Myers JS. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. BMJ Qual. Saf. 2013.

31

Diagnostic Error

Systems Issues

Lack of Knowledge

Cognitive Factors

32

7%

19%

28%

46%

Categories of factors contributing to diagnostic error in 100 patients

No Fault Factors Only

Systems-Related Factors Only

Cognitive Factors Only

Both System-Related andCognitive Factors

Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13).

83%

14%

3%

Cognitive Contributions to Error

Faulty Synthesis of Informationor Flawed Processing

Faulty Data Gathering

Inadequate or FaultyKnowledge

Graber, M. L., Franklin, N., & Gordon, R. (2005). Diagnostic error in internal medicine. Archives of Internal Medicine, 165(13).

Cognitive errors are defined as errors related to the way we think

and make diagnostic and treatment decisions.

Reilly JB, Ogdie AR, Von Feldt JM, Myers JS. Teaching about how doctors think: a longitudinal curriculum in cognitive bias and diagnostic error for residents. BMJ Qual. Saf. 2013.

Residents need this.

Survey conducted of our residents in 2013: • 75% think it is important to disclose cognitive errors to patients and

families • 90% think it is important to discuss cognitive errors with attendings • 98% believe that reducing cognitive errors will improve patient

safety. • Only 54% had seen discussion of cognitive error modeled by their

attendings.

• Only 31% felt encouraged by their supervisors to discuss cognitive errors

• Residents who were encouraged by their attendings to discuss cognitive errors were more likely to be aware of error reduction strategies (42 vs 18%, p<0.05)

Yee, Ruedinger and Olson

Group Exercise

• Divide into groups

• Read the case and then answer the questions that follow

• Put yourself in the team’s shoes

Choosing a New Curriculum

• Why now?

• How will it fit?

• Sustainability?

• Downstream and upstream support?

• Synergies?

Diagnostic Error Curriculum at Your Institution

• Take a few minutes at your table to discuss how this content could fit in

– Key faculty and institutional champions

– Likely settings

– Opportunities/Threats

– Outcomes you might track

Cognitive Bias Curriculum at University of Minnesota

• Key Faculty—Andrew Olson, Emily Ruedinger, Maren Olson

• Block education and morning reports

• Outcomes

Thank you for coming today!

z.umn.edu/diagnosticerror