how to teach about cognitive bias

Tom Benzoni benzonit at GMAIL.COM
Tue Jan 22 13:03:22 UTC 2019


Dr. Bell
These are follow-on errors.
When I take a history, if I start with the patient having it not having a
disease, that's what I'll find.
On physical, I'm validating, not questioning or disproving my history.
In my small experience, students are trained to prove, not debunk, their
diagnoses.
Tom




On Tue, Jan 22, 2019, 06:17 Robert Bell <
0000000296e45ec4-dmarc-request at list.improvediagnosis.org wrote:

> Overall, in diagnosis what is more important, cognitive biases or errors
> in history/physical, testing, and differential diagnosis? Any estimates?
>
> Rob Bell, MD
>
> Sent from my iPad
>
> On Dec 6, 2018, at 12:05 PM, Thomas Westover <
> 000000040134e744-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG
> <000000040134e744-dmarc-request at list.improvediagnosis.org>> wrote:
>
> 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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>
>
>
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Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine


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