how to teach about cognitive bias

Pat Croskerry croskerry at EASTLINK.CA
Mon Jan 21 21:36:02 UTC 2019


Tom: Agreed that it is important to have a knowledge of decision making and all that goes with it in the pre-clinical stages. Our approach at Dalhousie Medical School is to expose students to cognitive bias (and other issues that compromise rational decision making) in the first few months of medical school. The teaching materials were developed through the Critical Thinking Program that was established here 5 years ago. The CT mandate is to embed the CT approach in all 4 years of UGME, in various electives and webinars for PGME, and in ongoing presentations for all disciplines in the medical school, and in CME/CPD.

A major challenge has been keeping teaching faculty, tutors and instructors, on board. To help, we developed TACT (Teaching and Assessing Critical Thinking) -  <https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/TACT.html> https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/TACT.html - an online asynchronous faculty development program that is offered about twice a year, with a cohort of about 20 or so folk each time it is offered. It was initially developed for Dalhousie faculty but is now open to all. We also developed other teaching and assessment  strategies for faculty here. 

For our UGME - we developed a webpage which has a number of resources on it - you can access some of the content  at  <https://medicine.dal.ca/departments/core-units/DME/critical-thinking.html> https://medicine.dal.ca/departments/core-units/DME/critical-thinking.html . Undergrads are encouraged to access the resources there - video lectures, graphics, one-pagers (one page of concise information on major concepts), lists and definitions of biases and cognitive fallacies, references, etc. They also get two 1-hour foundational lectures in first year, and several further presentations in second year on special topics, and in clerkship. They have workshops on CT and are evaluated formatively and summatively in the skilled clinician program - we have developed a bank of about 50 MCQs. We have also developed a teaching manual that uses clinical cases - the ACTAM Manual (Applied Cognitive Training in Acute Medicine) for a UGME resource. Oxford University Press is publishing it this year as The Cognitive Autopsy. We encourage use of the Fishbone analysis in clerkship tutorials that James Reilly described in the context of clinical reasoning.

Pat

 

 

From: Tom Benzoni <benzonit at gmail.com> 
Sent: January 21, 2019 3:57 PM
To: Society to Improve Diagnosis in Medicine <IMPROVEDX at list.improvediagnosis.org>; Pat Croskerry <croskerry at eastlink.ca>
Subject: Re: [IMPROVEDX] how to teach about cognitive bias

 

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 <mailto: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 <mailto:rmsbell200 at yahoo.com> > 
Sent: January 20, 2019 5:15 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG> ; Pat Croskerry <croskerry at EASTLINK.CA <mailto: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 <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 <https://madmimi.com/p/fa0e2d?fe=1&pact=76716-148560539-8457174274-2b6f035f60fb4d603a886574b0a5af25e2c8ab1d> &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 – 

 

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)
 <mailto:Lorie.Slass at ImproveDiagnosis.org> Lorie.Slass at ImproveDiagnosis.org
Phone: 215.801.4057
 <http://www.improvediagnosis.org/> www.improvediagnosis.org 


 

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
 <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=> www.isabelhealthcare.com

 

 


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