how to teach about cognitive bias

Seiji Hayashi seiji.hayashi at NPC.HUMANDX.ORG
Tue Jan 22 14:39:28 UTC 2019


Thanks Ralph!

History taking is definitely one of the most important aspects of accurate
diagnosis because 80% of diagnoses are made on history alone. We're hoping
that by exercising your brain to think about the various diagnoses possible
for any series of clinical findings, your history taking will also improve.
The disease scripts and clinical schemas that we use to generate the
differential diagnosis as you go through each case should help make you a
better history taker.

One of our most important goals is to make the cases as short as possible
yet impactful. Emerging studies show that quick repetitions may be more
educational than a few detailed exercises. That's why our cases are short,
and people find it fun and engaging.


ᐧ

On Mon, Jan 21, 2019 at 10:27 PM Ralph Pinnock <ralph.pinnock at otago.ac.nz>
wrote:

> Hi Seiji
>
>
> I try to start the day with a paediatric case  from Human Dx
>
> What it does not test is history taking   -  data gathering
> This critical when it comes to diagnosis
>
> Some of us made virtual patients in its heyday about 10 yeras ago
> These are probably the best simulators for clinical reasoning
>
> Keep up the good work
>
> Ralph
>
>
>
> Ralph Pinnock FRACP MClin Ed
> Associate Dean Medical Education,
> Associate Professor,
> Department of Women and Children's Health,
> Dunedin School of Medicine
> PO Box 56,
> Dunedin,
> New Zealand.
>
> *)*
>
>
>
> ------------------------------
> made vertual in it heyday (about 10 years ago)
> *From:* Seiji Hayashi <seiji.hayashi at NPC.HUMANDX.ORG>
> *Sent:* Tuesday, January 22, 2019 5:31 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] how to teach about cognitive bias
>
> Great discussion here on simulations! I agree that measurement and
> validation is a really difficult piece.
>
> Last week, researchers from Johns Hopkins studied data from Human Dx and
> published a paper, "Assessment of a Simulated Case-Based Measurement of
> Physician Diagnostic Performance"
> <https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720591> in
> JAMA Network Open.
>
> Here are the *Key Points* cut and pasted from the article:
>
> *Question*  Can automated scoring by an online case-based simulator be
> used as a valid measure of diagnostic performance?
> *Findings*  This cohort study found that health care professionals with
> more experience and training demonstrated higher diagnostic performance
> scores, as measured on an online case simulator, The Human Diagnosis
> Project (Human Dx). Attending physicians were most efficient and accurate
> in diagnostic performance compared with residents, interns, and medical
> students.
> *Meaning*  Online case-based physician performance measurement has the
> potential to be a practical and scalable method in the assessment of
> diagnostic performance.
>
> Although Human Dx is not a flight simulator-like simulation, it simulates
> the cognitive reasoning. I would love to hear people's thoughts on this
> paper.
>
> Seiji
>>
> On Mon, Jan 21, 2019 at 8:48 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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>> To learn more about SIDM visit:
>> http://www.improvediagnosis.org/
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>>
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>> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
>> Medicine
>>
>> To learn more about SIDM visit:
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>> Medicine
>>
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>> http://www.improvediagnosis.org/
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>>
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>> --
>> The Human Diagnosis Project.
>> One open system.
>> For all of humankind.
>> Together.
>>
>
> --
> The Human Diagnosis Project.
> One open system.
> For all of humankind.
> Together.
>
> ------------------------------
>
>
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>
>
> Moderator:David Meyers, Board Member, Society for Improving Diagnosis in
> Medicine
>
> To learn more about SIDM visit:
> http://www.improvediagnosis.org/
>
>

-- 
--
The Human Diagnosis Project.
One open system.
For all of humankind.

Together.






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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