Motivated reasoning

Pat Croskerry croskerry at EASTLINK.CA
Wed Jan 18 20:46:43 UTC 2017


Bill: The development of new approaches towards medical decision making and
diagnostic error are important advances in medical education, and long
overdue. As a community, we have been slow to incorporate the findings from
cognitive science that are relevant to medical decision making – arguably,
the most critical aspect of patient care. I like ‘clinical reasoning
conference’ – that seems to put the focus in the right place.

Your new online curriculum sounds great – I would be very interested in
seeing it at the earliest opportunity. Agreed that it is unnecessary to have
learners attempt to memorise lists of biases but at least develop an
awareness (and humility) regarding the ways in which they intrude into
clinical decision making. There have been several useful approaches so far
aimed at categorising them. 

The think out loud strategy is a useful process – what it does is move
decision making and reasoning into System 2. But we have to keep in mind
that at the clinical interface, much decision making never reaches this
level of consciousness. The non-verbalised decision  remains unchallenged in
System 1, and is potentially dangerous. 

The rare and esoteric cases are often interesting but the ones most likely
to get the patient into trouble are the common ones where, for many reasons,
we think we know what’s going on but may be missing things completely. There
is burgeoning support for this in the literature,  and it seems to fit well
with what we see in clinical practice. To paraphrase a famous baseball
player:  it ain’t what we don’t know that gets us into trouble so much as
not thinking enough about what we do know i.e. a procedural problem rather
than a declarative one. Case-based examples, and plenty of them, are the
sine qua non.

Great work!

Pat

 

 

 

From: Follansbee, William [mailto:follansbeewp at UPMC.EDU] 
Sent: January 18, 2017 3:09 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Motivated reasoning

 

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:  <mailto:follansbeewp at upmc.edu> 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:  <mailto:follansbeewp at upmc.edu> follansbeewp at upmc.edu

 



 

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From: Pat Croskerry [ <mailto:croskerry at EASTLINK.CA>
mailto:croskerry at EASTLINK.CA] 
Sent: Friday, January 13, 2017 2:07 PM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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>
mailto:graber.mark at GMAIL.COM] 
Sent: January 13, 2017 1:50 PM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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-rea
soning/

 

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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