1. Recognizing Clinical Reasoning Errors Heidi Chumley, MD Associate Professor, Family Medicine

2. Session Objectives At the end of this session, participants should be able to: –Outline the steps of the clinical reasoning process. –Define cognitive dispositions to respond (CDRs) and describe several CDRs seen with diagnostic reasoning errors. –Recognize clinical reasoning errors in common educational settings.

3. Clinical Reasoning “the cognitive process necessary to evaluate and manage a medical problem” Reasoning KnowledgeSkill

4. Medical Errors 44,000 to 98,000 deaths per year due to medical errors Many systematic and individual factors contribute to medical errors Recent attention on cognitive errors (clinical reasoning, diagnostic reasoning, decision-making)

5. Cognitive Errors Zhang, JAMIA, 2002

6. Cognitive Errors Of 301 Malpractice claims, 59% involved diagnostic errors that led to poor outcomes – Gandhi, 2006 Of patients admitted with 10 days of outpatient visit, 10% due to diagnostic error – Singh, 2007 Autopsy series showed 24% missed diagnosis – Shojania, 2003

7. Diagnostic process Diagnosis Verification Diagnosis Refinement Differential Diagnosis Generation Information gathering

8. Why are errors made? Failure/delay of eliciting information – Singh, 2007 Suboptimal weighing of critical pieces of information from H&P – Singh, 2007 Overreliance on diagnostic testing – Bordage, 1999

9. Cognitive Dispositions to Respond Biases that can lead to diagnostic errors Mental shortcuts running amuck Croskerry defines 32, Acad Med, 2003: 78(8)

10. Cognitive Dispositions to Respond Information-gathering –Unpacking –Availability –Anchoring –Premature closure System –Diagnosis momentum –Feedback sanction –Triage cueing Probability –Aggregate bias –Base-rate neglect –Gender bias –Gambler’s fallacy –Posterior probability error Croskerry, 2003

11. Information-gathering problems Unpacking – failure to elicit all relevant information Availability – recent exposure influences diagnosis Anchoring – holding onto a diagnosis after receiving contradictory information Premature closure – accepting a diagnosis before it is fully verified Present at all levels, start watching for these in students

12. Clues to Information-Gathering Problems Limited differential diagnosis (unpacking, availability) Lack of attention to contradictory information (anchoring) Lack of pertinent negatives (premature closure)

13. Diagnostic Errors Diagnosis Verification Diagnosis Refinement Differential Diagnosis Generation Information gathering Unpacking Availability Anchoring Premature closure

14. Systems contributions Diagnosis momentum – early diagnosis by another provider is accepted as definite Feedback sanction – final diagnosis does not return to initial decision-maker Triage cueing – location cues management (seen through the lens of the first provider) Present at all levels, more likely to see in residents

15. Clues to System Contributors Lack of primary symptom data (diagnostic momentum) Inattention to closing the loop (feedback sanction) Non diagnoses: non-cardiac chest pain; no gynecologic cause for lower abdominal pain (triage cueing)

16. Probability Pitfalls Aggregate bias – aggregate data do not apply to my patients Base-rate neglect – ignoring the true prevalence Gender bias – gender inappropriately colors probability Gambler’s fallacy – sequence of same diagnoses will not continue Posterior probability – sequence of same diagnoses will continue Best seen during continuity experiences, residency

17. Clues to Probability Pitfalls Didn’t meet criteria, but I…(aggregate) Rare diagnoses high on list, increased testing (base-rate neglect) Comments about probability (Gambler’s fallacy, posterior probability)

18. Two Others Representative restraint – ruled out because the presentation is not typical Search satisfying – search is called off when something is found

19. Summing Up Reasoning errors are common Identifying/naming the CDRs is an important part of reflection No gold standard for assessing reasoning in our learners – nothing to replace our conversations and helping them think about how they are thinking Are cognitive errors treatable? Yes

20. Questions?