how to teach about cognitive bias

Sherrill Franklin sfranklin131 at GMAIL.COM
Mon Jan 21 01:22:12 UTC 2019


Hi Rob,

Here’s a paper that evaluates the simulators…  Validation seems to be a concern, so maybe more time is needed. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4205038/

Best,
Sherrill


Sherrill Franklin
129 E. Harmony Road
West Grove, PA 19390

EMAIL: sfranklin131 at gmail.com
PHONE:  (610) 869-4234

> On Jan 20, 2019, at 7:00 PM, Robert Bell <rmsbell200 at yahoo.com> wrote:
> 
> Thanks Sherrill,
> 
> These all sound very interesting.
> 
> Would welcome hearing about what are the hurdles are to overcome.
> 
> Rob Bell
> 
> On Sunday, January 20, 2019, 3:48:53 PM MST, Sherrill Franklin <sfranklin131 at GMAIL.COM> wrote:
> 
> 
> Dear Dr. Bell,
> 
> Yes~ Simulators could provide great training for every conceivable medical situation—from helping practitioners with cognitive bias, to identifying invisible, but debilitating autoimmune diseases to burn care.  Here are some uses (below) of simulators already “in the works.” One is a collaboration with Harvard/MIT, another is in use for plastic surgeons, another for brain surgery. Some of these articles are a bit old, so, as you mentioned, maybe there were obstacles that prevented further development. Or perhaps, these capable people just need a bit more running room to work out the kinks...
> 
> https://harvardmedsim.org/training/simulation-instructor-training/ <https://harvardmedsim.org/training/simulation-instructor-training/>
> 
> https://news.wisc.edu/flight-simulator-for-surgeons-project-joins-computer-science-with-medicine <https://news.wisc.edu/flight-simulator-for-surgeons-project-joins-computer-science-with-medicine>
> 
> https://www.technologyreview.com/s/415104/a-simulator-for-brain-surgeons/ <https://www.technologyreview.com/s/415104/a-simulator-for-brain-surgeons/>
> 
> 
> My best,
> 
> Sherrill Franklin
> 129 E. Harmony Road
> West Grove, PA 19390
> 
> EMAIL: sfranklin131 at gmail.com <mailto:sfranklin131 at gmail.com>
> PHONE:  (610) 869-4234
> 
>> On Jan 20, 2019, at 4:15 PM, Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:
>> 
>> Dear Pat Kroskerry,
>> 
>> Sounds promising,
>> 
>> I have always felt that medical training would be enhanced using airline flight simulator-like approaches.
>> 
>> Have these been introduced to medicine yet, and are they effective?
>> 
>> Not having heard a lot about such training either here or elsewhere I am presuming that there are intrinsic problems as it pertains to medicine? 
>> 
>> If so it would be sad when one considers the tremendous improvement in Safety by the global airline industry over the last 50 years or so.
>> 
>> Is it true that there ARE significant problems?
>> 
>> Rob Bell, M.D.  
>> 
>> On Sunday, January 20, 2019, 10:55:58 AM MST, Pat Croskerry <croskerry at EASTLINK.CA <mailto:croskerry at EASTLINK.CA>> wrote:
>> 
>> 
>> Tom: apologies for the delay in responding. I believe this approach has significant potential for teaching about diagnostic failure.
>> 
>> Jonathan Howard has just published a case-based guide to critical thinking in medicine: Cognitive errors and diagnostic mistakes (Springer) – a great resource.
>> 
>> We have been using a similar approach here at Dalhousie for a number of years. Our teaching manual which documents in detail about 40 cases of cognitive error in diagnosis will be published by OUP this year.
>> 
>> Another useful exercise is to take the cases published by Charles Pilcher (Medical Malpractice Insights (MMI): Learning from Lawsuits) and work out the cognitive biases likely involved. https://madmimi.com/p/fa0e2d?fe=1&pact=76716-148560539-8457174274-2b6f035f60fb4d603a886574b0a5af25e2c8ab1d <https://madmimi.com/p/fa0e2d?fe=1&pact=76716-148560539-8457174274-2b6f035f60fb4d603a886574b0a5af25e2c8ab1d>   
>> 
>>  
>> Pat Croskerry MD, PhD, FRCP(Edin)
>> 
>> Professor, Department of Emergency Medicine,
>> 
>> Director, Critical Thinking Program,
>> 
>> Dalhousie University Medical School,
>> 
>> Halifax, Nova Scotia
>> 
>> CANADA
>> 
>>  
>>  
>>  
>>  
>> From: Thomas Westover <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> 
>> Sent: December 7, 2018 2:03 AM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] how to teach about cognitive bias
>> 
>>  
>> Thanks for that tip Lorie
>> 
>>  
>> I spent a little time today glancing thru the tool kits; It seems that they are more academic overviews than specific examples
>> 
>>  
>> would it be worthwhile for the SIDM community to "crowd source" and have interested SIDM members submit short (1-2 paragraph) case descriptions/illness scripts that illustrate specific cognitive biases (anchoring premature closure etc etc)
>> 
>>  
>> these could be reviewed by an ad hoc expert group of senior SIDM leaders for vetting and then posted on the SIDM website for dissemination to residency program directors, medical school faculty members etc
>> 
>>  
>> I would certainly be interested in such a teaching tool
>> 
>>  
>> Thanks
>> 
>> Tom
>> 
>>  
>>  
>> Thomas Westover MD
>> 
>> Cooper Medical School
>> 
>> NJ
>> 
>>  
>>  
>>  
>>  
>> On Thursday, December 6, 2018, 2:32:44 PM EST, Lorie Slass <Lorie.Slass at IMPROVEDIAGNOSIS.ORG <mailto:Lorie.Slass at IMPROVEDIAGNOSIS.ORG>> wrote:
>> 
>>  
>>  
>> There is info on the SIDM site that may be helpful –
>> 
>>  
>> Assessment of Reasoning Tool <https://www.improvediagnosis.org/art/> – this was developed as a tool to support educators in assessing a learner’s clinical reasoning skills during patient presentations. On the page there are a number of videos that look at elements of clinical reasoning.
>> The Clinical Reasoning Toolkit <https://www.improvediagnosis.org/clinicalreasoning/> includes great resources.  Resources in the ‘how we make decisions’ section includes many that focus on cognitive bias - https://www.improvediagnosis.org/clinical-reasoning-toolkit-how-we-make-decisions/ <https://www.improvediagnosis.org/clinical-reasoning-toolkit-how-we-make-decisions/>
>> We maintain a ‘foundational reading’ section <https://www.improvediagnosis.org/foundational-readings/> that includes readings/studies related to cognitive reasoning.
>>  
>> Hope these are helpful.
>> 
>>  
>>  
>> _________________________________________
>> 
>> Lorie Slass
>> Vice President of Communications and Marketing
>> Society to Improve Diagnosis in Medicine (SIDM)
>> Lorie.Slass at ImproveDiagnosis.org <mailto:Lorie.Slass at ImproveDiagnosis.org>
>> Phone: 215.801.4057
>> www.improvediagnosis.org <http://www.improvediagnosis.org/> 
>> <image001.jpg>
>> 
>>  
>> From: Thomas Westover <000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG <mailto:000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> 
>> Sent: Thursday, December 6, 2018 2:05 PM
>> To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] how to teach about cognitive bias
>> 
>>  
>> Does the sidm website have a list of short case presentations that are good examples of the various cognitive biases that have been reviewed in the literature ?
>> 
>>  
>> I would like to do a short cognitive bias review session at the beginning of our weekly M&M rounds 
>> 
>>  
>> To teach students and residents about what these constructs are and how they are relevant in decision making 
>> 
>>  
>> And to teach them that understanding clinical reasoning is just as important as obtaining the correct dx
>> 
>>  
>> Thanks
>> 
>>  
>> Tom
>> 
>>  
>> Thomas Westover MD
>> 
>> Sent from my iPhone
>> 
>> 
>> On Dec 6, 2018, at 1:04 PM, Jarrett, Mark P <MJarrett at NORTHWELL.EDU <mailto:MJarrett at NORTHWELL.EDU>> wrote:
>> 
>> Mark
>> 
>>  
>> I agree – but we often see anchoring based on the initial diagnosis that leads to less than ideal outcomes. The key to me is both a good differential (don’t always have to be right out of the gate) and purposeful reflection and re-evaluation.
>> 
>>  
>> Mark
>> 
>>  
>>  
>> Mark Jarrett, MD, MBA, MS
>> 
>> SVP & Chief Quality Officer
>> 
>> Associate Chief Medical Officer
>> 
>> Northwell Health
>> 
>> Professor of Medicine
>> 
>> Zucker School of Medicine at Hofstra/Northwell
>> 
>> (O): 516-321-6044
>> 
>> (C): 917-796-3935
>> 
>> mjarrett at northwell.edu <mailto:mjarrett at northwell.edu>
>>  
>>  
>>  
>> From: Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>
>> Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>
>> Date: Thursday, December 6, 2018 at 11:31 AM
>> To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
>> Subject: [EXTERNAL] Re: [IMPROVEDX] DX measures
>> 
>>  
>> External Email. Use Caution.
>> 
>> Jason – thanks for continuing to press us all to develop practical measures we could all support that would lead to improved diagnosis. 
>> 
>>  
>> I do agree that concordance between an admission and discharge diagnosis might be one measure of the adequacy of the diagnostic process in the ambulatory setting.  But at the end of the day, I’d argue that ‘getting it right’ is likely more important than getting it right in the clinic alone.
>> 
>>  
>> The agreement between admission and discharge diagnosis is fairly easy to measure and study, but this parameter is complicated !  First, in many hospitals the discharge diagnoses are assigned by coders whose primary goal seems to be centered on optimizing billing, not to capture diagnostic accuracy.  Second, and I may be old-fashioned here, but in my humble opinion there is no better time or place to make a diagnosis or to revise an initial impression.  It is so much easier to concentrate on a patient’s problems, consider and complete diagnostic evaluations, and get opinions from others during an inpatient stay compared to stretching these out over time and space in the ambulatory setting.  In this framework, any difference between the admitting and the discharge diagnosis is likely to be to the patient’s advantage and a good thing.  The disagreement noted in this study is almost certainly multifactorial, but if I had to guess, this data may be saying something positive about the diagnostic process in showing that the recorded diagnosis did in fact evolve during the admission.
>> 
>>  
>>     Mark
>> 
>>  
>> Mark L Graber, MD FACP
>> 
>> Chief Medical Officer; Founder and President Emeritus, SIDM
>> 
>> Professor Emeritus, Stony Brook University, NY
>> 
>>  
>>  
>> From: Jason Maude <jason.maude at ISABELHEALTHCARE.COM <mailto:jason.maude at ISABELHEALTHCARE.COM>>
>> Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>, Jason Maude <jason.maude at ISABELHEALTHCARE.COM <mailto:jason.maude at ISABELHEALTHCARE.COM>>
>> Date: Thursday, December 6, 2018 at 9:41 AM
>> To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>
>> Subject: [IMPROVEDX] DX measures
>> 
>>  
>> This is a very interesting study (freely available) looking at the degree of match between the admission diagnosis and what the authors call the exit diagnosis.
>> 
>>  
>> “Our results show that only the 21.67% of cases are identified correctly on admission….”
>> 
>>  
>> Could this be used as a measure for diagnosis quality in hospitals? I am sure there will be concerns about the admitting diagnosis and clinicians being rushed to put something down without enough time but the ratio between the 2 diagnoses for an institution as a whole should be a useful indicator as would the trend over time. If the measure drove institutions to focus of getting the admitting diagnosis more accurate then that would be good.
>> 
>>  
>> This should also be practical to produce as would not involve the clinicians in any additional work.
>> 
>>  
>> In an earlier discussion, I asked if there were any measures that were practical, where there were no concerns and that we could all support but got replies. I really feel that if we are to get diagnosis the respect it deserves from hospitals and health systems then we need a measure. We have all been talking about this for a long time, but I do not sense we are any further forward!
>> 
>>  
>> Regards
>> 
>>  
>> Jason Maude
>> 
>> Founder and CEO Isabel Healthcare
>> Tel: +44 1428 644886
>> Tel: +1 703 879 1890
>> www.isabelhealthcare.com <https://urldefense.proofpoint.com/v2/url?u=http-3A__www.isabelhealthcare.com_&d=DwMGaQ&c=vq5m7Kktb9l80A_wDJ5D-g&r=OdFSWyd_9B_X_P7v0350Bl1aeyp7F5zA-lXlf2CKjKY&m=INGksrWRy1zKL1BamDNx4gGE4MQC_2HOGsslUu-ViF0&s=ShMxvrMch6y0Y-mkw58wVE9-hhgufGxXNmOuQJa0I0w&e=>
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>> <image001.jpg>
> 
> 
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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