how to teach about cognitive bias

Tom Benzoni benzonit at GMAIL.COM
Mon Jan 21 19:56:46 UTC 2019


Where would this group suggest teaching about cognitive biases?
I'm at the pre-clinical years teaching level now; I can't find curricular
room (because they're learning about a syndrome found in 6 people out of
the world population?)
Yet they need this knowledge prior to clinical years, I think.
SIM would be a natural fit...but I think only clinicians realize how
important this topic is (after we've committed a few ourselves.)

Thoughts?

Is there any research into where cognitive biases actually are taught in
pre-clinical years?

tom

On Mon, Jan 21, 2019 at 7:48 AM Pat Croskerry <croskerry at eastlink.ca> wrote:

> Thus far, simulation appears to be relatively undeveloped in teaching
> about cognitive bias. It would seem a reasonable approach, and I did see it
> used some time ago for running codes in a medical school program at Monash
> in Australia.
>
> They would set the trainee up for specific cognitive traps e.g. search
> satisficing, anchoring, to illustrate biases and then address them in
> debriefing. I don’t think it was ever written up. Also, Bill Bond did some
> simulation work on cognition which was published (Bond W et al,
>  Cognitive versus technical debriefing after simulation training. *Acad
> Emerg Med* 2006; 13: 276-283).
>
> Also, PRI, a Physician’s insurers group in Long Island developed some
> scenarios using actors where they simulated some common cognitive biases.
>
> I’m also aware of other groups that have used filmed clinical simulations
> to illustrate various cognitive biases.
>
> Given that it is unlikely to be restricted from a technological
> standpoint, it has potential.
>
> Pat
>
>
>
>
>
>
>
>
>
> *From:* Robert Bell <rmsbell200 at yahoo.com>
> *Sent:* January 20, 2019 5:15 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; Pat Croskerry <
> croskerry at EASTLINK.CA>
> *Subject:* Re: [IMPROVEDX] how to teach about cognitive bias
>
>
>
> 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> 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
>
>
>
>
> 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>
> *Sent:* December 7, 2018 2:03 AM
> *To:* 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> wrote:
>
>
>
>
>
> There is info on the SIDM site that may be helpful –
>
>
>
>    1. 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.
>    2. 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/
>    3. 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 <Lorie.Slass at ImproveDiagnosis.org>*
> Phone: 215.801.4057
> www.improvediagnosis.org
> [image:
> https://c.ymcdn.com/sites/improvediagnosis.site-ym.com/resource/resmgr/images/New_SIDM_logo.jpg]
>
>
>
> *From:* Thomas Westover <
> 000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>
> *Sent:* Thursday, December 6, 2018 2:05 PM
> *To:* 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>
> 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
>
>
>
>
>
>
>
> *From: *Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG>
> *Reply-To: *Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Mark Graber <
> Mark.Graber at IMPROVEDIAGNOSIS.ORG>
> *Date: *Thursday, December 6, 2018 at 11:31 AM
> *To: *"IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <
> 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>
> *Reply-To: *Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>,
> Jason Maude <jason.maude at ISABELHEALTHCARE.COM>
> *Date: *Thursday, December 6, 2018 at 9:41 AM
> *To: *Listserv ImproveDx <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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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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