Motivated reasoning

Follansbee, William follansbeewp at UPMC.EDU
Wed Jan 18 19:09:11 UTC 2017


Pat,

As always, very edifying.   We recently published the first six of planned 9 modules of an online curriculum that we have developed on medical decision making and diagnostic error.  The first six modules represent about 2 ½ hours of course content. The last three modules will be based upon my cognitive checklist concept to help guide bedside decision making, which we hope to have up and running by March. All 200 internal medicine residents and interns, including transitionals, have now  taken or are currently finishing the first six modules, and all 160 students in the 3rd year medical school class will be taking the curriculum  this academic year. The rounding teaching faculty in medicine will also be taking the curriculum. Once the whole curriculum is finished, we plan to make it available to other departments such as family medicine, pediatrics and emergency medicine to see if they would have an interest in using it.

In developing the curriculum, we took the approach that the purpose of learning about biases was to try to help make physicians (or other care givers) aware of them and the potential cognitive traps into which they might fall in their day to day decision making, with the hope that perhaps that awareness can help improve decision making.  There is a vast array of these biases, as you know better than probably better than anyone, but so many are very similar,  such as myside bias vs confirmation bias.  We felt that it was probably unnecessary and from a practical standpoint impossible for clinicians to know about all of them, to remember them or most of all to use them. Instead, we grouped the most common biases that seem to be most directly relevant to diagnostic reasoning and diagnostic error into 5 broad categories. Obviously the categorization is inherently very arbitrary, and 5 different people might do it 5 different ways, but that may not be so important. In the curriculum, we present and explain each major category and the biases which we included in each one so that learners gain some general awareness and understanding of them in a little bit of depth. But our goal is not to have them try to remember them all but only try to remember and use the 5 major categories. We felt that was a more practical and manageable number from the standpoint of usability in day to day practice. If they can keep and use those major categories in their active day to day memory as they are seeing patients, we hypothesized that that might be enough to achieve a very similar benefit in hopefully improved diagnostic accuracy and cost efficiency as they might get by trying to learn and remember 20 or 30 or 200.  So far, the approach has been very well received.

To reinforce the concepts of the information presented in the curriculum, we have integrated clinical reasoning into virtually every aspect of the training program experience. We changed the monthly Chief of Medicine conference, which used to be a formal presentation from a senior faculty member, into a clinical reasoning conference. Each month, a senior faculty clinician is presented a completely unknown case. The residents present the case but importantly we also have a faculty moderator to guide the discussion. The case is presented in segments, after which there is a pause and the discussant "thinks out loud" describing what they are considering at that point, how they integrate the information, what other information or findings they might seek, and how they are developing their dx and differential dx. They are explaining their reasoning. The goal is not so much necessarily to get the right diagnosis, although that is always nice, but to illustrate the reasoning process that experienced and skilled clinicians use.  That is where the moderator role is particularly helpful to help guide the discussion, sometimes ask residents in the audience questions or for comments, etc.  The cases are specifically selected not to be rare NEJM CPC type cases but instead are cases with more common diagnoses, perhaps with atypical presentations. At the end, there is a brief discussion of biases that might have had a role clinically.  The format has been very well received.

Clinical reasoning is also then prioritized into discussions in morning report, attending rounds, M&M, etc. We are learning as we go but it has been an interesting and fun experience. The curriculum has content presented in different formats including text, audio, videos of expert discussants, and quizzes and is largely case-based in much of its content. In some of the cases, we used hired actors and photos with audio to make them a little more engaging. We have also included some animation, including of your iconic illustration that you kindly allowed us to use. When we finish the last three modules with the discussion of my checklist, I'll arrange for you to get a link to see the curriculum, including how we animated your illustration. Once we complete the curriculum, we plan to follow up with a "case of the month" selected to illustrate diagnostic errors and information that was in the curriculum. Our thought is that if our simple type 2 analytic processes are used longitudinally over the course of a 3 year training experience, they might begin to be incorporated into type I reasoning processes. We'll see.

You are an inspiration.

Best,

Bill

William P. Follansbee, M.D., FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-647-3437
Fax: 412-647-3873
Email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>


From: Pat Croskerry [mailto:croskerry at eastlink.ca]
Sent: Sunday, January 15, 2017 5:30 PM
To: 'Society to Improve Diagnosis in Medicine'; Follansbee, William
Subject: RE: [IMPROVEDX] Motivated reasoning

Hi Bill and Gerrit.
I don't see much difference between myside bias ('... when people evaluate evidence, generate evidence, and test hypotheses in a manner biased toward their own prior opinions and attitudes - Stanovich et al, 2013), and confirmation bias (...the tendency to seek confirmation for opinions and beliefs already held and to ignore disconfirming evidence - Nickerson, 1998). Maybe myside bias is a bit more consciously deliberate, whereas with confirmation bias we tend not to be so aware? Motivated reasoning seems to be taking confirmation bias to a higher level ('Motivated reasoning leads people to confirm what they already believe, while ignoring contrary data. But it also drives people to develop elaborate rationalizations to justify holding beliefs that logic and evidence have shown to be wrong. Motivated reasoning responds defensively to contrary evidence, actively discrediting such evidence or its source without logical or evidentiary justification. Clearly, motivated reasoning is emotion driven' - Skeptics dictionary)
As far as positive test strategy goes, I think it came down to a psychologist (Wason) using confirmation bias to explain the results of a study he had done looking at subject's responses to finding a rule which applied to sets of numbers. He would give them a series of 3 numbers and they would have to guess what the rule was and he would tell them whether they were correct or not on successive tries. Their strategy appeared to be attempts to confirm the rule rather than to try to disprove the rule - hence Wason's conclusion. However, other psychologists came along later and labelled it a Positive Test Strategy which they felt was aimed at a simpler approach - choose a strategy that has the biggest impact on your belief in your current hypothesis. This does appear to differ slightly from confirmation bias.
As with most biases, there appear to be others that are doing the same thing, and any differences are fairly subtle e.g.  I sometimes get into discussions with students who can't see a difference between search satisficing and premature closure - it is there.
I think the important thing is to be aware that biases are there, whether we get their exact identity of not - Linnaeus might have disagreed!

Pat


From: Follansbee, William [mailto:follansbeewp at UPMC.EDU]
Sent: January 15, 2017 2:41 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Motivated reasoning

Hi Pat,

I am wondering how myside bias is different from confirmation bias? They seem to be very similar.

Best,
Bill

William P. Follansbee, M.D., FACC, FACP, FASNC
The Master Clinician Professor of Cardiovascular Medicine
Director, The UPMC Clinical Center for Medical Decision Making
Suite A429 UPMC Presbyterian
200 Lothrop Street
Pittsburgh, PA 15213
Phone: 412-647-3437
Fax: 412-647-3873
Email: follansbeewp at upmc.edu<mailto:follansbeewp at upmc.edu>

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From: Pat Croskerry [mailto:croskerry at EASTLINK.CA]
Sent: Friday, January 13, 2017 2:07 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Motivated reasoning

The description of motivated reasoning looks very similar to that for myside bias (but doesn't sound quite so derogatory).
Myside bias is well described in the cognitive psychology literature, and its relevance to medicine is beginning to be felt.
______________________________________
Pat Croskerry MD, PhD
Professor, Department of Emergency Medicine,
Director, Critical Thinking Program,
Dalhousie University Medical School,
Halifax, Nova Scotia
CANADA




From: Mark Graber [mailto:graber.mark at GMAIL.COM]
Sent: January 13, 2017 1:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Motivated reasoning

For those with an interest in cognitive psychology, this is a fascinating look at 'motivated reasoning'.  I'm not sure how much of this is relevant to decision-making in diagnosis, but it certainly helps explain the tension many of us feel in having a political discussion these days ;<)

http://theness.com/neurologicablog/index.php/more-evidence-for-motivated-reasoning/

Mark L Graber, MD FACP
President, SIDM
Senior Fellow, RTI International
Professor Emeritus, Stony Brook University, NY

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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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