Biases and debiasing Pat Croskerry MD, PhD

Affective Cognitive Social/Cultural The Biases Affective Cognitive Social/Cultural

Affective Bias When the affective state of the decision maker adversely affects decision making Due to a failure in rational/logical decision making Usually due to ‘hot emotion’ (vivid-tepid continuum) There are about 20 known affective biases Universal Predictable Correctable (affective de-biasing)

The Emotional Spectrum HOT COOL

Cognitive and affective debiasing

Four 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 unaware of the problem…

And some people will never change…

So how do we become better decision makers ?

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

The most important step is de-coupling from System 1

T Calibration Diagnosis Type 1 Processes Pattern Recognition Patient RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override Dysrationalia override T Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED

Executive override 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 maintain a feral vigilance to detect biases

It ain’t easy Even though bias detected Very unlikely one strategy works for all Need for multiple approaches Very unlikely one shot will work Need for multiple innoculations Need for extra vigilance in critical conditions Need for lifelong maintenance

Issues that impede cognitive and affective de-biasing

Variable Descriptor Clinical relevance Lack of awareness 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 Strategies Teach the basic rationale: DPT and where errors are Review the main cognitive and affective biases Teach specific strategies for particular biases Forcing functions Encourage decision maker to get more information Encourage metacognition and reflection Slow down Think the opposite Maintain a healthy skepticism Group decision making Educating intuition Less hubris, less overconfidence

High Risk Situations Cognitive overloading Fatigue Sleep deprivation/sleep debt Negative mood/affective state Alcohol/drug influence

High risk situations 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                                    

The Ultimate Debiasing Strategy? What else could this be?