SIDM's priority: Translating ideas into action

Eta S Berner eberner at UAB.EDU
Mon Nov 9 16:44:14 UTC 2015


There are really two issues-one is identifying the main cause of diagnostic errors and the other is figuring out how to address the problem.  Even if cognitive errors were identified as the cause (which clearly they are at least some of the time), that does not automatically determine how one would fix the problem.  Although one might think that cognitive errors should be addressed by cognitive (e.g. educational) strategies, that is not the only choice.

*********************************************
Eta S. Berner, Ed.D.
Professor, Health Informatics
Director, Center for Health Informatics for Patient Safety/Quality<http://www.uab.edu/shp/hsa/chipsqhome>
Department of Health Services Administration
School of Health Professions
Professor, Department of Medical Education
School of Medicine
University of Alabama at Birmingham
1705 University Blvd. #590J
Birmingham, AL 35294
Phone: (205)975-8219
Fax:       (205)975-6608
Email:   eberner at uab.edu

From: Marius Laurent [mailto:marius.laurent at SKYNET.BE]
Sent: Monday, November 09, 2015 9:15 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] SIDM's priority: Translating ideas into action

Pat :

This is a very documented answer, but it is only partly convincing. Of course if you look at them retrospectively, you can identify flaws in knowledge and in reasoning in many instances of diagnostic errors, but are there the only (root) causes of the diagnostic failure? Many retrospective studies based their conclusions on opinions, interpretations and not on facts. The study of Zwaan used a taxonomy (the so called Eindhoven classification used to code unintended events during healthcare). It contains 23 possibilities, with half of them devoted only to human factors. "What you find is what you are looking for" (you may call it hindsight bias). Another recent study points to the differences between observers in interpreting the causes of diagnostic errors (Warrick C. Diagnostic error in children presenting with acute medical illness to a community hospital. Int J Qual Health Care 2014 ; 26 : 538-46). From the point of view of EBM, expert opinion is only weak evidence.

I did not know the work of Higgins. His subject is far away of diagnostic errors made by professionals. I cannot really argue with critical thinking. The slave standing behind the roman general during his triumph saying "memento mori" (remember you wil die sometimes...) is probably the first published example. What I expected is again a firm evidence that it can change something when speaking about diagnostic error.

Understand me. I am not fluent in English, and maybe I may seem inappropriately aggressive:  it is not what I intend to do. But I am afraid that by putting too much an attention on "human factors", without  solid evidences, we'll discourage a lot of physician to engage themselves in a serious research on diagnostic errors. Just remember the article of Berwick,  Not again! (Br Med J 2001;322:247-8): preventing errors lies in redesign, not exhortation!

I'm a (retired) intensivist, working now  with the Health federal public service in Belgium. I try to mobilize professionals around the problem of diagnostic error, and it is not an easy task.

Marius Laurent

De : Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Envoyé : dimanche 8 novembre 2015 15:08
À : IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Objet : Re: [IMPROVEDX] SIDM's priority: Translating ideas into action

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/  - 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<mailto: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 <mark.graber at IMPROVEDIAGNOSIS.ORG<mailto: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<http://www.improvediagnosis.org>
919 990-8497
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