1. Decision making
Satisficing is a decision-making strategy that entails searching through the evidence and available alternatives until an acceptability threshold is met (the level of uncertainty has been reduced to a level at which the individual feels comfortable to make a decision). This is contrasted with optimal decision making, an approach that specifically attempts to find the best alternative available

2. Mindlines
“Clinicians rarely accessed, appraised, and used explicit evidence directly from research or other formal sources; rare exceptions were where they might consult such sources after dealing with a case that had particularly challenged them.”
Gabbay and le May. BMJ 2004; 329: 1013–1016

3. “Instead, they relied on what we have called "mindlines,” collectively reinforced, internalised tacit guidelines, which were informed by brief reading, but mainly by their interactions with each other and with opinion leaders, patients, and pharmaceutical representatives and by other sources of largely tacit knowledge that built on their early training and their own and their colleagues' experience.”

4. Principles Decisions are processes, not events
Tendency to view the decision as ok / not ok
Probably more helpful to think about HOW we go about making decisions rather than WHAT decision should we make / has been made
What is system 1 telling me, do I need to work it out with system 2, am I at risk of a cognitive or affective bias in system 1, am I missing something (calibration)?

5. 1 2 Calibration Diagnosis TYPE Context Modular responsivity
Ambient conditions
Task difficulty
Task ambiguity
Affective state
Modular responsivity
Intellectual Ability
Education
Training
Critical thinking
Logical competence
Rationality
Feedback
Pattern Recognition
Repetition
Rational
override
Dysrationalia
Calibration
Diagnosis
Patient
Presentation
Pattern
Processor
RECOGNIZED
TYPE 1
processes 2
NOT
Neal
How can dual process models mitigate diagnostic error?
A single model that explains the wide variety of decisions that are made is a major simplification
The specific operating characteristics of the model can be tested in particular clinical situations
The model can be readily taught to learners across a wide range of disciplines
Understanding the model allows more focused metacognition
The described features of the model can generate specific research questions about decision making processes in particular situations
Croskerry 2009 5

6. Diagnosis Rx

7. Consciously incompetent
System 2
System 2
Assess
Learn
Consciously competent
Unconsciously incompetent
Practice
Lapse
System 1
System 1
Unconsciously competent

8. 2 ways to improve our performance
Alerting the analytical mode to situations in which a bias might arise so that it can be detected and an intervention applied.
Mitigate the impact of adverse ambient conditions, either by improving conditions in the decision making environment, or by changing the threshold for detection of bias.

9. A caveat
Biases have multiple determinants, and it is unlikely that there is a ‘one-to-one mapping of causes to bias or of bias to cure;
Neither is it likely that one-shot debiasing interventions will be effective.
It’s COMPLEX, not COMPLICATED
BUT People quite often change their minds and behaviours for the better.

10. >50 cognitive biases Anchoring bias – early salient feature
Ascertainment bias – thinking shaped by prior expectation
Availability bias – recent experience dominates evidence
Bandwagon effect – we do it this way here
Omission bias – natural disease progression preferred to those occurring due to action of physician
Sutton’s slip – going for the obvious
Gambler’s fallacy – I’ve seen 3 recently; this can’t be a fourth
Search satisficing – found one thing, ignore others
Vertical line failure – routine repetitive tasks leading to thinking in silo
Blind spot bias – other people are susceptible to these biases but I am not

11. Was this patient handed off to me from a previous shift
Was this patient handed off to me from a previous shift? Diagnosis momentum, framing
Was the diagnosis suggested to me by the patient, nurse or another physician? Premature closure, framing bias
Did I just accept the first diagnosis that came to mind? Anchoring, availability, search
satisficing, premature closure
Did I consider other organ systems besides the obvious one? Anchoring, search satisficing, premature closure
is this a patient I don’t like, or like too much, for some reason? Affective bias
Have I been interrupted or distracted while evaluating this patient? All biases
Am I feeling fatigued right now? All biases
Did I sleep poorly last night? All biases
Am I cognitively overloaded or overextended right now? All biases
Am I stereotyping this patient? Representative bias, affective bias,anchoring, fundamental attribution error, psych out error
Have I effectively ruled out must-not-miss diagnoses? Overconfidence, anchoring, confirmation bias

12. Metacognition
“The process by which we reflect upon, and have the option of regulating, what we are thinking”
The Cognitive Imperative: Thinking about How We Think
Croskerry Academic Emergency Medicine
standing back & observing our own thinking

13. Features of Metacognition
Awareness of the learning process and the cognitive demands of a particular situation
Recognition of the limitations of memory
Ability to appreciate the broader perspective
Capacity for self critique
Ability to select a particular strategy for improving the decision making, particularly when things don’t fit
Simon 13

14. Cognitive Forcing Strategies For Improved Performance
Consider alternatives
Routinely think: “if I am wrong what else might this be”
ROWcS
Seek incongruent data
Don’t be afraid to try and prove you are wrong
Reframe when recording
Mentally reconsider meaning
Reassess the associations YOU have created
Kurt/Simon
Clinical examples 14

15. Personal Strategies For Improved Performance 2
Reconsider dissonant facts
Take a step back from the problem
Know and understand test accuracy
Tests are only so good
Tests are only as good as the questions you ask of them
Use time as a diagnostic tool
Careful, watchful, wait and see is NOT the same as inactivity
Kurt/Simon
Clinical examples 15

16. Personal Strategies For Improved Performance 3
Decrease reliance on memory
Use cognitive aids (but use them wisely):
Decision support, mnemonics, guidelines, algorithms etc.
Try to make tasks easier
e.g. Calculate drug doses on paper (not in your head)
Kurt/Simon
Clinical examples 16

17. Personal Strategies For Improved Performance 4
Be aware of own affective state
Especially time pressures
Be aware of our decision mode
Establish accountability in a given situation
Who is doing what?
Who is responsible for what?
Non-judgemental, constructive feedback
Be a giver; be a welcoming receiver
Kurt/Simon
Clinical examples 17