Presentation is loading. Please wait.

Presentation is loading. Please wait.

Dual Process and Cognitive Bias in Clinical Decision Making

Published byRobert Harrell Modified over 9 years ago

Similar presentations

Presentation on theme: "Dual Process and Cognitive Bias in Clinical Decision Making"— Presentation transcript:

1 Dual Process and Cognitive Bias in Clinical Decision Making
Joan M. Von Feldt, MD, MSEd Professor of Medicine

2 Thinking Fast and Slow Daniel Kahneman

3 Approaches to Decision Making
Modular responsivity Hypothetico-deductive reasoning Gestalt effect Deliberation without attention Inductive reasoning Robust Decision Making Normative reasoning Thin Slicing Recognition Primed Exhaustion Strategy Bayesian reasoning Heuristics and Biases Bounded rationality Intuitive Analytical Croskerry. Adv in Health Sci Ed 2009; 14:27-35

4 Properties of the 2 types of decision-making
System I (Intuitive) System II (Analytical) Cognitive Style Heuristic Systematic Cognitive Awareness Low High Automaticity Rate Fast Slow Effort Emotional Component Scientific Rigor Errors More Less These are the two extremes of the spectrum of decision making. Simple tasks can be solved using heuristics ( i.e. rules of thumb, intuition abbreviation and simple judgments) Heuristics are helpful such as giving fluids to hypotensive patients but also can fail because too simplistic. The key for clinicians is realizing when the complexity of case is greater and requires a analytical and more time consuming approach. As people become experts more use of system 1 is possible, because of improved pattern recognition or possibly the converse of being able to recognize when things do not fit a pattern and need to move to system 2. 4

5 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 Annotations After a single course of treatment, RTX + MTX maintained responses in the majority of patients for up to 48 weeks. At 48 weeks, ACR20, 50, and 70 responses were significantly better for the RTX + MTX arm compared to MTX alone. The percentage of EULAR responders was greater in the RTX + MTX arm compared to MTX alone. CTX does not appear to provide any additional benefit over MTX, and therefore, combinations with CTX are not being pursued further in clinical trials.

6 Model for diagnostic reasoning based on
pattern recognition and dual-process theory Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract Sep;14 Suppl 1:27-35.

7 Heuristics Pattern Recognition Illness Scripts Gestalt
Instance Scripts i.e “Blink”; “Thinking Fast” Annotations After a single course of treatment, RTX + MTX maintained responses in the majority of patients for up to 48 weeks. At 48 weeks, ACR20, 50, and 70 responses were significantly better for the RTX + MTX arm compared to MTX alone. The percentage of EULAR responders was greater in the RTX + MTX arm compared to MTX alone. CTX does not appear to provide any additional benefit over MTX, and therefore, combinations with CTX are not being pursued further in clinical trials.

8 Heuristics Can be good: Can be bad:
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 Annotations After a single course of treatment, RTX + MTX maintained responses in the majority of patients for up to 48 weeks. At 48 weeks, ACR20, 50, and 70 responses were significantly better for the RTX + MTX arm compared to MTX alone. The percentage of EULAR responders was greater in the RTX + MTX arm compared to MTX alone. CTX does not appear to provide any additional benefit over MTX, and therefore, combinations with CTX are not being pursued further in clinical trials. Croskerry, P. Acad Med 2003; 78:

9 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

10 Systems Errors: Complicated

11 Cognitive Errors: Just As Complicated…But In A Different Way

12 Cognitive Error Categories
Faulty Knowledge Faulty Data Gathering Faulty Information Processing Faulty Verification Annotations After a single course of treatment, RTX + MTX maintained responses in the majority of patients for up to 48 weeks. At 48 weeks, ACR20, 50, and 70 responses were significantly better for the RTX + MTX arm compared to MTX alone. The percentage of EULAR responders was greater in the RTX + MTX arm compared to MTX alone. CTX does not appear to provide any additional benefit over MTX, and therefore, combinations with CTX are not being pursued further in clinical trials.

13 to both Systems and Cognitive
Origins of diagnostic error in 100 patients 19% related to Systems Error Didn’t expand your differential diagnosis….. 28% related to Cognitive Error 46% related to both Systems and Cognitive Errors Forgot to f/u on the blood cultures… Poor communication among consultants….. Leape LL, et al. N Engl J Med 1991; 324(6): Graber ML. Franklin N. Gordon R. Diagnostic error in internal medicine. Archives of Internal Medicine, 2005; 165(13):

14 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:

15 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:

16 Availability Availability bias
Judge things as being more likely if they readily come to mind Croskerry, P. Acad Med 2003; 78:

17 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:

18 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

19 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:

20 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

21 Cognitive Bias Can Lead to Errors in Diagnosis

22 How Do We Deconstruct Our “Brick Walls”?

23 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”?

24 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 Annotations After a single course of treatment, RTX + MTX maintained responses in the majority of patients for up to 48 weeks. At 48 weeks, ACR20, 50, and 70 responses were significantly better for the RTX + MTX arm compared to MTX alone. The percentage of EULAR responders was greater in the RTX + MTX arm compared to MTX alone. CTX does not appear to provide any additional benefit over MTX, and therefore, combinations with CTX are not being pursued further in clinical trials.

25 ???

Download ppt "Dual Process and Cognitive Bias in Clinical Decision Making"

Similar presentations

Nursing Diagnosis: Definition

Nursing Diagnosis: Definition
Critical Thinking and Decision Making Arnuparp Lekhakula Faculty of Medicine Prince of Songkla University Hat Yai, Songkhla.

Critical Thinking and Decision Making Arnuparp Lekhakula Faculty of Medicine Prince of Songkla University Hat Yai, Songkhla.
The Sociology of Health Access to health professions Lecturer: Elspeth Cordell.

The Sociology of Health Access to health professions Lecturer: Elspeth Cordell.
Who is Karl Popper? And what has he done to us?.

Who is Karl Popper? And what has he done to us?.
Teaching and Assessing Critical Reasoning in the Era of Competency-based Medical Education, Milestones and Entrustment Preventing Diagnostic Error.

Teaching and Assessing Critical Reasoning in the Era of Competency-based Medical Education, Milestones and Entrustment Preventing Diagnostic Error.
Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014.

Reducing Diagnostic Error Tim Shoen, MD Campaign for Quality October 17, 2014.
Errors in the diagnostic process Hierarchy of Qualities in Medicine Frequency of diagnostic Errors Judgment under Uncertainty: Heuristics and Biases The.

Errors in the diagnostic process Hierarchy of Qualities in Medicine Frequency of diagnostic Errors Judgment under Uncertainty: Heuristics and Biases The.
Decision making Satisficing is a decision-making strategy that entails searching through the evidence and available alternatives until an acceptability.

Decision making Satisficing is a decision-making strategy that entails searching through the evidence and available alternatives until an acceptability.
Biases and debiasing Pat Croskerry MD, PhD

Biases and debiasing Pat Croskerry MD, PhD
Recognizing Clinical Reasoning Errors Heidi Chumley, MD Associate Professor, Family Medicine.

Recognizing Clinical Reasoning Errors Heidi Chumley, MD Associate Professor, Family Medicine.
Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric.

Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric.
Diagnosing – Critical Activity HINF 371 - Medical Methodologies Session 7.

Diagnosing – Critical Activity HINF Medical Methodologies Session 7.
Clinical decision making Carl Thompson UK, Centre for Evidence Based Nursing Editor, Evidence Based Nursing www.ebn.bmj.com.

Clinical decision making Carl Thompson UK, Centre for Evidence Based Nursing Editor, Evidence Based Nursing
Decision Making Styles

Decision Making Styles
The Nature of Managerial Decision Making

The Nature of Managerial Decision Making
Clinical Reasoning Skills STEPP Course ST1;2014 Peter Macfarlane.

Clinical Reasoning Skills STEPP Course ST1;2014 Peter Macfarlane.
A Summary Of Key Findings From A National Survey Of Voters. #07160.

A Summary Of Key Findings From A National Survey Of Voters. #07160.
The Culture of Healthcare Nursing Care Processes Lecture b This material (Comp2_Unit6b) was developed by Oregon Health and Science University, funded by.

The Culture of Healthcare Nursing Care Processes Lecture b This material (Comp2_Unit6b) was developed by Oregon Health and Science University, funded by.
East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Research methods: answering questions.

East & South East England Specialist Pharmacy Services East of England, London, South Central & South East Coast Research methods: answering questions.
Topic 5 Understanding and learning from error. LEARNING OBJECTIVE Understand the nature of error and how health care can learn from error to improve patient.

Topic 5 Understanding and learning from error. LEARNING OBJECTIVE Understand the nature of error and how health care can learn from error to improve patient.

Similar presentations

Ads by Google