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

Jain, Bimal P.,M.D. BJAIN at PARTNERS.ORG
Tue Nov 14 15:41:14 UTC 2017


Thanks Dr. Shojania for your comments.
I agree completely with you that heuristics work most of the time in diagnosis. In fact, I would say that diagnosis would not be possible without heuristics.
A heuristic, as I see it is a method of plausible reasoning when we have incomplete or fragmentary data. It employs notions such as resemblance, analogy, imaginative reconstruction etc. to suspect a disease from a presentation to arrive at a possible explanation which is then formulated as a hypothesis.
It plays a vital role thus in the first stage of diagnosis which is hypothesis generation. It is a method of discovery as its name implies ( in Greek heuriisken= discovery ).
An error occurs when we consider the end product of heuristic application to be a confirmed disease which is not correct as a heuristic is not a method of proof. A heuristic does not provide any evidence for a disease.
The important role of heuristics in generating fruitful hypotheses in science and mathematics is well known. For example, Einstein developed his revolutionary hypothesis of particle nature of light by heuristic reasoning as is evident from the title of his paper ‘ Concerning an heuristic point of view toward the emission and transformation of light.’ This hypothesis was considered correct only when it was experimentally confirmed many years later.
The noted mathematician G Polya has written about the importance of heuristics as plausible reasoning in his book ‘ How to solve it ‘.
I believe an appreciation of the role of heuristics only in formulation of a diagnostic hypothesis and not in its confirmation would minimize diagnostic errors.
Bimal

From: Shojania, Dr. Kaveh [mailto:Kaveh.Shojania at SUNNYBROOK.CA]
Sent: Thursday, November 09, 2017 1:58 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] The status of heuristics and cognitive biases as a source of diagnostic errors.

I can see both sides of this debate/discussion.

I think one of the reasons for questioning the importance of heuristics as a cause of diagnostic errors is not the issue of frequency. It’s more the following: heuristics are so often associated with diagnostic successes, that it’s hard to argue they are the major problem.

If something (in this case,  set of heuristics) works 95% of the time, then it’s hard to say it’s a problem. or, rather, it’s hard to argue that it should be abandoned

The vast majority of diagnoses are correctly made within less than a minute. That’s a combination of pattern recognition and ‘common things being common’.

So, to say that heuristics are to blame for most/many diagnostic errors doesn’t really make sense, since they are reasonable for most diagnostic successes.

It doesn’t help that the same behavior will be called diagnostic acuity when it’s correct and a cog bias when it is not – in other words, it is not really possible to distinguish diagnostic acumen from diagnostic bias until the outcome is known, which means it’s not that helpful of a concept in terms of preventing errors.

Except that, if one does want to reduce diagnostic errors, one needs to do something. And, that something is not so much to get rid of heuristics it is to recognize when one needs to shift to more deliberate and systematic thinking.

Sometimes that can happen during the first encounter with a patient – the patient says something or the doctor notices something that doesn’t fit the pattern. The good diagnostician is not the person who avoids heuristics, but the one who listens to the little voice in their head saying ‘Something’s not quite right - time to step back and think about this more’

This is what many say about System I vs System Ii , thinking fast, thinking slow, etc

So, I am not saying anything original here. I am just pointing out that it maybe it’s a semantic point. But, I think it is a bit more than that.

We have a situation that heuristics turn up frequently both in cases that do involve errors in diagnosis  and ones that do not.

From an epidemiologic point of view, that usually means that heuristics can’t be a major cause of error. That’s why we do case control studies – if the exposure turns up as often among cases as among controls, it’s not a risk factor for the disease of interest.

This happens a lot in patient safety. One does a root cause analysis of a critical incident and identifies that the resident on the team was new that day, there was a temp nurse from an agency, the patient didn’t speak English etc etc

It’s tempting to jump on each of these as important causes of whatever bad thing happened.  The problem is that these same factors are present in so many other cases where nothing went wrong. The reality is that each of these factors may well play a small contributory  role. From a logical point of view, though, it’s still hard to argue that X commonly causes Y, when X is commonly present in so many cases of Not Y. And, from a practical point of view, when X leads to a desirable outcome most of the time, why not do it and just get better at recognizing when that’s not working? (In practice, we get good not just at recognizing when it is not working out now, but recognizing critical situation where the patient would suffer a bad outcome before we have time to shift our thinking. Eg, , that’s why one constructs a differential diagnosis when seeing an cutely unwell patient – because one doesn’t want the patient to suffer a bad outcome before one realizes the need to shift out of heuristic mode.)


-kgs





Kaveh G. Shojania, MD
Professor and Vice Chair, Quality & Innovation
Department of Medicine
Director, University of Toronto
Centre for Quality Improvement and Patient Safety (www.cquips.ca<http://www.cquips.ca/>)

Sunnybrook Health Sciences Centre
Room H468, 2075 Bayview Avenue
Toronto, Ontario M4N 3M5

Editor-in-chief, BMJ Quality & Safety

From: Grubenhoff, Joe [mailto:Joe.Grubenhoff at CHILDRENSCOLORADO.ORG]
Sent: Thursday, November 09, 2017 1:17 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] The status of heuristics and cognitive biases as a source of diagnostic errors.

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<mailto: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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