Diagnostic error - cause or outcome, event or process

Pat Croskerry croskerry at EASTLINK.CA
Wed Apr 12 14:21:48 UTC 2017


Those three are key to how the world works! Do you have the psychologists’ reference for the ‘3 general types of fallacies’?

I thoroughly enjoyed the way you presented these concepts in your book. 

Pat

 

From: John Brush [mailto:jebrush at ME.COM] 
Sent: April 12, 2017 11:10 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic error - cause or outcome, event or process

 

I think it is useful to make this simple for learners. Psychologists say that there are 3 general types of fallacies: hasty judgments, distorted probability estimates, and biased judgments. One can get a bit more specific and talk about premature closure, framing, priming, and stereotyping, but I try to keep it simple. I have a chapter on “Common Fallacies” in my book “The Science of the Art of Medicine.”

John

 

John E. Brush, Jr., M.D., FACC

Professor of Medicine

Eastern Virginia Medical School

Sentara Cardiology Specialists

844 Kempsville Road, Suite 204

Norfolk, VA 23502

757-261-0700

Cell: 757-477-1990

jebrush at me.com <mailto:jebrush at me.com> 

 

 

 

On Apr 12, 2017, at 9:59 AM, Pat Croskerry <croskerry at EASTLINK.CA <mailto:croskerry at eastlink.ca> > wrote:

 

Peter: this is all relatively new material, and there is no short snappy paper I’m aware of yet in medicine (I’m working on it).

 

This paper is good but may be a little advanced from a beginner’s perspective: Stanovich, KE.(2011). On the Distinction Between Rationality and Intelligence: Implications for Understanding Individual Differences in Reasoning. In KJ. Holyoak & RG. Morrison (Eds). (pp. 343-365). The Oxford handbook of thinking and reasoning. Oxford, England: Oxford University Press.

There is a more comprehensive treatment of the topic in this recent book:  <https://www.amazon.ca/s/ref=dp_byline_sr_book_1?ie=UTF8&field-author=Keith+E.+Stanovich&search-alias=books-ca> Stanovich, KE, West, RF, <https://www.amazon.ca/s/ref=dp_byline_sr_book_3?ie=UTF8&field-author=Maggie+E.+Toplak&search-alias=books-ca>  & Toplak, ME. (2016). The rationality quotient: toward a test of rational thinking. Cambridge, MA: MIT Press.

As well (apologies for the shameful self-promotion) there are a couple of chapters that go into the topic in our upcoming book: Croskerry, Cosby, Graber, & Singh. Diagnosis. Interpreting the shadows. Boca Raton, Fla: CRC Press (2017: forthcoming). I think the publication date is June.

Pat

 

 

 

 

From: Elias Peter [ <mailto:pheski69 at GMAIL.COM> mailto:pheski69 at GMAIL.COM] 
Sent: April 11, 2017 9:43 PM
To:  <mailto:IMPROVEDX at list.improvediagnosis.org> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Diagnostic error - cause or outcome, event or process

 

Excellent and useful feedback.

 

Here’s a follow-up question. If I were working with a training program (say, a family practice residency) and wanted to help them understand rationality and avoid the commonest sources of cognitive misfire (I hate the word failure), can you identify a handful of references or resources that they might find useful?

 

Peter Elias

 

 

On 2017.04.11, at 8:10 PM, Pat Croskerry < <mailto:croskerry at eastlink.ca> croskerry at eastlink.ca> wrote:

 

Thanks Peter and for your earlier contributions to this discussion.

Bob Latino’s blog raises a number of important issues.

The para towards the end that begins: When talking to the decision maker… gives a good feel for the complexity of the diagnostic process, especially if one is attempting a cognitive RCA.

Individual factors that influence decision making are multifarious and Bob mentions some of the main ones – others are age, gender, and personality of the decision maker.

 

Cognition is invisible for the most part, and inferences are vulnerable to hindsight and outcome bias.

However, I don’t think the problem is insurmountable. 

The cognitive scientists have been busy for the last few years on how we make decisions.

One of the major concepts to emerge has been the notion of individual rationality – largely missing from extant RCAs. 

1.	In terms of decision making, rationality is now considered superlative to all else – it trumps critical thinking and intelligence.
2.	It is no longer seen as binomial i.e. that someone is either rational or not, but rather is distributed, just like intelligence – thus some folk will be more rational than others (this doesn’t necessarily mean smarter )
3.	Rationality can now be measured on appropriate tests – it is possible to calculate an RQ score (rationality quotient) – consider including it on medical school admissions?
4.	Importantly, we know the main sources of rationality failure – they are (a ) cognitive miserliness (tendencies to treat information superficially or with insufficient effort), (b) mindware gaps (missing bits of critical information, failures in probability reasoning etc),  and (c) mindware contamination – logical failures in reasoning, cognitive biases, eccentric reasoning.

 

If people understood these three main sources of cognitive failure and how to recognise them, as well some of the other major factors that influence individual cognition, and were mindful of hindsight and outcome bias, a reasonable stab at a cognitive RCA might be possible.

Pat Croskerry

 

 

From: Elias Peter [ <mailto:pheski69 at GMAIL.COM> mailto:pheski69 at GMAIL.COM] 
Sent: April 11, 2017 9:34 AM
To:  <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] Diagnostic error - cause or outcome, event or process

 

Bob Latino wrote an interesting blog post about error here:

 

 <https://www.linkedin.com/pulse/error-cause-outcome-bob-latino?published=t> https://www.linkedin.com/pulse/error-cause-outcome-bob-latino?published=t

 

(Disclaimer - he included a comment I provided as feedback when I read it.)

 

I think it is very pertinent to the discussions this group has about the nature of diagnostic error, and I’d be interested in hearing what the group thinks. I’ll hold off on contributing my thoughts to avoid framing the conversation.

 

 

Peter Elias, MD

 

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