SIDM's priority: Translating ideas into action

Pat Croskerry croskerry at EASTLINK.CA
Sun Nov 8 14:08:17 UTC 2015


Marius: it’s now about 35 years since the first direct studies of
physician’s thinking failures in decision making (Detmer et al, J Med Ed
1978).  Over that period cognitive science has made huge advances in how we
reason and make decisions. The gist of that work is that human reasoning,
judgment and decision making is often a flawed process, and as Detmer et al
noted: ‘A physician’s judgment is human judgment and susceptible to human
limitations’ i.e. we are just as vulnerable as others. For evidence, start
with the cognitive science literature. Typically, this is not read by the
medical community but that is where much of the evidence lies (for
references, see Croskerry Healthcare Quarterly 2012 and Croskerry Diagnosis,
2014). Examples of studies that have explicitly attributed cognitive factors
(thinking failures) to failed diagnostic reasoning are Graber et al, (Acad
Med 2002) Zwaan et al, (Arch Int med 2010). Estimates of ‘cognitive’ failure
range from 70% to over 90%. A number of other studies were reviewed in
Groopman’s popular book : How Physicians Think (2007). All of the major
disciplines in medicine have now acknowledged the important role of thinking
failures in clinical decision making(for references and suggested reasons
for failing to recognize the problem see Croskerry, Diagnosis 2014). 

 

On the second point for evidence of the effects of critical thinking you
could start at the National Foundation for Critical Thinking website
<http://www.criticalthinking.org/> http://www.criticalthinking.org/  -
coincidentally, also going for about 35 years. There are abundant references
there on the beneficial effects of critical thinking. For the meta-analytic
study I mentioned, see: Higgins et al, 2005 (A meta-analysis of the impact
of the implementation of thinking skills approaches on pupils. In: Research
Evidence in Education Library. London: EPPI-Centre, Social Science Research
Unit, Institute of Education, University of London). This large study found
that thinking skills were by far the most effective intervention for
improving reasoning and problem solving. The study of pupils in the age
range 5-16 years found a remarkable effect size of 0.62, the equivalent of
moving a class from the 50th to the 26th percentile – an impressive gain of
24 percentile points. Medical undergraduates and postgraduates are beyond
the age range of the group studied, however, from the limited studies on
development of critical skills, there do not appear to be any temporal
restrictions on when critical thinking interventions might be made.

For the ethical imperative to implement critical thinking into clinical
reasoning, see the excellent paper by Stark and Fins (The ethical imperative
to think about thinking. Diagnostics, metacognition, and medical
professionalism. Cambridge Quarterly of Healthcare Ethics 2014; 23:
386-396).

Pat 

  

 

From: Marius Laurent [mailto:marius.laurent at skynet.be] 
Sent: Thursday, November 05, 2015 11:35 AM
To: 'Society to Improve Diagnosis in Medicine'; 'Pat Croskerry'
Subject: RE: [IMPROVEDX] SIDM's priority: Translating ideas into action

 

Pat,

I like your proposition, but I must confess my surprise seeing your
affirmation about numerous studies proving the role of thinking failure in
diagnosis errors, and about meta-analytic studies demonstrating the efficacy
of critical thinking training. I desperately look for such evidences, maybe
you can help me?

Marius

 

De : Pat Croskerry [mailto:croskerry at EASTLINK.CA] 
Envoyé : mercredi 4 novembre 2015 21:52
À : IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Objet : Re: [IMPROVEDX] SIDM's priority: Translating ideas into action

 

Mark: these all look worthwhile initiatives.

I’d like to add a further one: given that a number of studies now point to a
significant proportion of diagnostic failure being due to thinking failures,
and given that meta-analytic studies demonstrate conclusively that by far
the most effective way of improving reasoning and problem solving skills is
through critical thinking interventions, I advocate for the introduction of
critical thinking interventions at UGME and PGME. Others have already
designated critical thinking as a meta-competency and some programs have
embarked on this in separate initiatives. Others in the ethics domain have
strongly proposed that this be done as an ‘ethical imperative’, and, given
the unacceptably high estimates of preventable deaths from diagnostic
failure it’s hard to argue with that.

Rather than each inventing our own wheels, how about developing a generic
Critical Thinking Module that would be available off the shelf that medical
educators could use? The content could be approved by a consensus committee.
This would be an inexpensive project with potentially high returns.

Pat



On 11/04/15 12:43 PM, Mark Graber <
<mailto:mark.graber at IMPROVEDIAGNOSIS.ORG> mark.graber at IMPROVEDIAGNOSIS.ORG>
wrote:


With the IOM report now officially out on the street, SIDM is now focused on
how to change practice to improve diagnosis.  The "Coalition to Improve
Diagnosis" will be our first priority; the Coalition steering committee has
had several meetings already, and the next steps are for each organization
to identify at least one action they can take, and for all the members to
agree on a common action. The Coalition will also be growing very soon to
include another set of key national organizations.

 

We are also urging federal agencies to step up to the plate.  Founding Board
member David Newman-Toker represented SIDM at a meeting yesterday of the
AHRQ National Advisory Committee, and publicly thanked AHRQ for being a key
supporter of our efforts through funding of our Diagnostic Error
Conferences, the IOM report itself, and through the new R01 and R18 grant
funding to study diagnostic error they have recently made available. We
asked the NAC to support 3 initiatives deriving from the IOM report:  1)
Developing a Common Format for organizations to report diagnostic errors to
their Patient Safety Organizations; 2) Working with DOD, HHS, VA and others
to develop the national research priorities for diagnosis, and to develop a
public-private partnership to promote research; and 3) Providing dedicated
funding for AHRQ to support research on diagnostic error in proportion to
the harm associated with diagnostic error.

 

Later this month I'll be addressing a group at the CDC to emphasize the
actions we'd like to see them take: 1) Resurrect the clinical pathologist
position by providing funding for this type of consultation; 2) Resuscitate
autopsies at key designated centers as a way to learn about errors; 3) Help
develop and use failsafe procedures for test reporting; and 4) Use second
opinions in anatomic pathology.  

 

We'll provide updates on these activities as they come up, and would love to
hear about initiatives that the listserv readership might also know about,
or be involved with.

 

  Mark

 

Mark L Graber MD FACP
President, SIDM  www.improvediagnosis.org
919 990-8497
 
<https://webmail.eastlink.ca/iwc/svc/wmap/attach/Logo%20-%20Medium%20PNG.png
?token=1nle44OMfe&mbox=INBOX&uid=69362&number=4&type=image&subtype=png> 

 


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