The status of heuristics and cognitive biases as a source of diagnostic errors.

Grubenhoff, Joe Joe.Grubenhoff at CHILDRENSCOLORADO.ORG
Thu Nov 9 06:17:09 UTC 2017


I too share a Dr. Isbell’s reluctance to claim that heuristics are not a significant source of diagnostic error.

Having read Thinking Fast and Slow, I think that Kahneman and Tversky point out not that heuristics represent faulty probabilistic reasoning but rather a complete disregard of probabilities.

In the Linda experiment, the subject is provided a series of data points that are not necessarily predictive of her likelihood of being a feminist  but the subject draws inferences that provide cognitive coherence which make the less probable (statistically speaking) combination of being a feminist and a bank teller seem more likely than simply being a bank teller (all feminist bank tellers are wholly contained within the larger population of bank tellers).

In contrast, the “analogous” experiment contains faulty logic. A man presenting with a case description consistent with a PE may also have a UTI but the probability that he has a UTI in the absence of any signs/symptoms or data predictive of a UTI is highly unlikely. Further, the Venn diagram for the populations of patients with UTI and with PE overlap but one does not wholly contain the other except in very unique circumstances. To put it differently, the prevalence of UTI and PE can be known as, theoretically, could the presence of both existing together. But it cannot be taken as given that in all circumstances one group wholly contains the other. Contrast this with Liinda: ALL cases of feminist bank tellers must be contained within the group “bank tellers.” I think most physicians would say that, in the absence of a more reasonable alternative answer (Jim has only a PE), they would be forced to choose “Jim has a UTI and PE” but would scratch their heads as to why those were the only two answers provided as they are implausible.

Work by Frank Papa suggests that representativeness IS very likely a key component of arriving at a correct diagnosis. Cases with a more typical presentation (e.g. AMI) are more likely to be correctly diagnosed than cases in which the features are atypical.

I don’t understand this sentence: We note we do not need to invoke the heuristic of representativeness as an explanation for answer (a) because probabilistic reasoning has not been employed in this instance.

If the theoretical clinician choosing between answer (a) and (b) is not using representativeness (a heuristic strategy) and not using probabilistic reasoning, then how does she arrive at choosing (a) over (b). It seems the clinician choosing (a) is indeed using heuristics because she would have to ignore the improbable scenario in which Jim has a completely asymptomatic UTI in the presence of a PE (or alternatively, the clinical vignette is purposefully deceptive by leaving out any information about a UTI dx which is not reflective of actual practice).

The proposition that the solution to avoiding diagnostic errors requires “extensive knowledge and experience of diseases” ignores the finite capacity of the human mind and suggests the an approach to diagnosis that Marewski and Gigerenzer (Heuristic decision making in medicine - Marewski and Gigerenzer Dialogues in Clinical Neuroscience - Vol 14 . No. 1 . 2012) might call unbounded rationality. This is not an efficient (or even possible) strategy especially in light of the fact that the pre-test probabilities of many diseases based solely on history and exam findings are unknown and, at least in pediatrics, we have very few good screening and confirmatory tests for the conditions we encounter.

Lastly, while admittedly anecdotal, argues the point the Dr. Isbell made with respect to experienced physicians relying on wrong information when forming a diagnosis.

A previously physically normal teen female with a PMHX of depression and anxiety is being transferred from a community hospital after EMS was called to help change her diaper because she would not get out of bed to defecate. She had been admitted 2x in the preceding 3 weeks for “weakness” and both Psychiatry and Neurology had consulted agreeing that the patient suffered from conversion disorder. On the 2nd admission and LP to evaluated for Guillain Barre was normal as was an MRI of the brain and spinal cord. Presently the patient cannot move the lower extremities, has absent DTRs and is suctioning her mouth with a Yankauer due inability to swallow secretions. She is again diagnosed by the peds ER doc (Me) as conversion disorder but cannot be admitted to Psych due to inability to participate in ADLs so is admitted to the floor. After a few days she develops SVT and AMS and a repeat LP is performed showing albuminocytologic dissociation and a Dx of GBS is made.

If you gave me a test and asked: Are the CSF changes of GBS always present at the time of clinical manifestations of sx I would answer “no”. And I have cared for patients in the past with a similar scenario. Thus, I had the knowledge and the experience to know better. However, I anchored on the prior workup and allowed the psych-out error and Dx momentum to land on Conversion disorder as the diagnosis. I know the prevalence of neither so arguing that probabilities entered in to my diagnostic reasoning is unsubstantiated.

Good food for thought.

jg
From: Linda M. Isbell [mailto:lisbell at PSYCH.UMASS.EDU]
Sent: Wednesday, November 08, 2017 7:26 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] The status of heuristics and cognitive biases as a source of diagnostic errors.


Interesting paper, thanks for sharing it; however, I do disagree with the notion that heuristics and biases are not a significant concern in diagnosis.  A large body of research demonstrates the pervasive use of heuristics across pretty much every domain ever investigated over several decades.  This is not at all controversial in psychology.  So, it is unclear to me why diagnosis would be exempt from this - ???  I certainly agree that lack of medical knowledge or experience will certainly lead to diagnostic errors.  However, how do we explain diagnostic errors that emerge when a provider has both knowledge and experience?   One cannot assume, for example, that if an error occurs, one must not have had the knowledge or experience to reach the correct diagnosis (though this can be assessed).  Surely very smart and experienced doctors sometimes rely on the wrong information when assessing patients and forming a diagnosis - the same doctors who may well have the necessary information in their heads but, for some reason, they relied on something other than this information.

Best,

Linda
---
Linda M. Isbell, Ph.D.
Professor, Psychology
Department of Psychological and Brain Sciences
University of Massachusetts
135 Hicks Way -- 630 Tobin Hall
Amherst, Massachusetts 01003
Office Phone:  413-545-5960
Website:  http://people.umass.edu/lisbell/

On 2017-11-07 06:48, Jain, Bimal P.,M.D. wrote:
In this attached paper, I point out that heuristics and biases are a source of inferential errors only in a setting in which the normatively correct method of reasoning is probabilistic.
I argue that the notion of heuristics and biases as a source of diagnostic errors may not be relevant in diagnosis  which  is not probabilistic in practice as I point out in this paper.
I suggest the main sources of diagnostic errors are lack of knowledge and/or experience.
Please review and comment on this paper.
Thanks.

Bimal

Bimal P Jain MD
Northshore Medical Center
Lynn MA 01904.



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