Critical thinking and hardwired biases

Lorri Zipperer Lorri at ZPM1.COM
Sat Jul 27 19:56:40 UTC 2013

Forwarded by the moderator


From: Pat Croskerry [mailto:croskerry at] 
Sent: Saturday, July 27, 2013 6:35 AM
To: 'Society to Improve Diagnosis in Medicine'; 'Graber, Mark'
Subject: RE: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis


We have recently implemented a Critical Thinking P <<...>> rogram at
Dalhousie University Medical School. Core content includes teaching about
how we make decisions, cognitive biases and the impact of ambient influences
on our decision making. I will attach a list of 50 biases that we use in the
program that we believe are relevant to clinical medicine. Deborah's
experience can be understood in the context of 'psych-out error'.

Undoubtedly, some cognitive and affective biases are hard-wired and will be
difficult (although not impossible) to overcome. Many other biases are
simply learned and become established through habit - these may be easier to
deal with.

Pat Croskerry MD, PhD, FRCP(Edin)

Professor, Department of Emergency Medicine, 

Director, Critical Thinking Program, Division of Medical Education,

Faculty of Medicine,

Dalhousie University,

QE II - Health Sciences Centre,

Halifax Infirmary, Suite 355

1796 Summer Street, Halifax, Nova Scotia, B3H 2Y9 


-----Original Message-----
From: Graber, Mark [mailto:Mark.Graber at VA.GOV]
Sent: Thursday, July 25, 2013 9:10 PM
Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis

Deborah's stories, tragic as they are, convey an incredibly important lesson
for all of us interested in diagnostic error - namely that being more aware
of the possibility of diagnostic error can help prevent the next one.
Acknowledging that this is an 'n' of 1 demonstration, its still great to
hear that building awareness had an impact.

Pat Croskerry has argued in several of his papers that one way to reduce
diagnostic error is to teach the inherent shortcomings of heuristic
thinking.  I was initially unconvinced, on the grounds that these are
hardwired responses, and can't be unlearned.  Deborah's ability to discover
a new diagnostic error would seem to argue that we should score one in Pat's
favor, although I wonder what was the more dominant influence for Deborah:
knowledge of cognitive bias, or just knowledge that these errors are so

Mark Graber

Senior Fellow, RTI International

Founder and President, Society to Improve Diagnosis in Medicine


From: "Dr.Will" < <mailto:dr.will at FUSE.NET> dr.will at FUSE.NET>

Reply-To: Society to Improve Diagnosis in Medicine <
dr.will at FUSE.NET>

Date: Thu, 25 Jul 2013 16:32:00 -0400


Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis

Hello Deborah,

And then you add additional work the physician must do per patient
visit(EMR) taking them away from the patient and you end up with a
"misdiagnosis" because there was very little clinical time spent with the
patient due to extra work requirements.

So wrong diagnosis, but an effective billing software system so the hospital
was paid well. Seemingly at the expense of the patient.

It happens too frequently.

 Will Sawyer, MD

Solo Family Medicine

Cincinnati, Ohio


From: Deborah Akinniyi [ <mailto:deborah.akinniyi at YALE.EDU>
mailto:deborah.akinniyi at YALE.EDU]

Sent: Thursday, July 25, 2013 2:11 PM


Subject: Re: [IMPROVEDX] Crowd Wisdom, Premature psych conclusions, and harm
from misdiagnosis

Hello everyone,

My name is Deborah Akinniyi, and I'm an internal medicine resident who
became interested in diagnostic error during my third year of medical school
after my first patient died... When he died, I wept... and I was angry. My
team said there was nothing we could do, that these things happen, and that
with patients like him the outcome wasn't surprising. I didn't accept these
notions, because deep inside, a gnawing feeling told me we were wrong;
despite the type of patient he was, or the psychiatric and medical
comorbidities he had, his death could have been prevented.

These feelings pulled and pushed me towards careful review of his case,
acceptance that even the most seasoned doctors make mistakes, and my
introduction to diagnostic error. I confirmed that we were wrong, and found
that my patient's story was an unfortunate case of delayed diagnosis,
cognitive biases, and diagnostic error proved deadly. Since then, I've
remained interested in reducing diagnostic error through various means,
including sharing my experiences with other physicians so that we can all
learn from it.

I have a case of a patient who was being "dismissed as psych" so strongly
that her inspiratory chest pain, palpitations, and sinus tachycardia were
dismissed as consequences of her pre-existing psychiatric disorders. Prior
to coming on service, I was told that she was completely fine, had no
current medical issues, and was just waiting for an inpatient psych bed. I
was told, "Don't be alarmed if she complains of chest pain... It's just the
way her anxiety presents." I was even given specific instructions not to
pursue a pulmonary embolism (PE) work-up... "She does not have a PE."

It turns out, this patient had multiple PE's. She also had a personal
history of spontaneous abortions, and a family history of blood clots.
Later, we confirmed that in addition to her pre-existing psychiatric
disorders, she has a genetic clotting disorder.

When I reflect on this case, I'm forced to realize that had I not been aware
of how common various biases can lead to delayed diagnosis and diagnostic
error, this woman may have continued to go untreated, worsening her physical
health, and her concerns may have continued to be minimized and dismissed,
worsening her mental health. I also suspect that patients with pre-existing
psychiatric disorders likely suffer from delayed and misdiagnosis more
commonly, and agree that the implications this has on the financial burden,
patient safety, mental health, physical health, and the overall
doctor-patient relationship in this group are frightening.

I plan to fully analyze this case from a diagnostic error standpoint and to
review the literature on the specific biases that affect the care of
patients with pre-existing psychiatric disorders. I plan to eventually write
a case report on this, and am sure that through that process, I'll learn
even more about diagnostic error and how to prevent it. If any of you have
experiences, articles, or papers you'd like to share, please send them my
way! Also, if you have any questions for me, or any advice to help me as I
continue through residency and develop as a physician, I'm all ears and open
for mentorship. I'm inspired by you all, and I look forward to continuing
these conversations.


Deborah Akinniyi


Deborah C. Akinniyi, MD, MS

Yale Internal Medicine Residency Program

MD, George Washington University, '12

MS/BS, Stanford University, '08

Website:  <>

Email:  <mailto:deborah.akinniyi at> deborah.akinniyi at,
<mailto:chinenye at> chinenye at



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