how to teach about cognitive bias

Nelson Toussaint ntoussaint at TAMARAC.COM
Wed Jan 23 15:01:57 UTC 2019


 

 

January 23, 2019

9:04 AM

Cognitive Bias in aircraft pilot training in Simulators

 

All Bias is considered in pilot functioning through the use of 2 principles:

 

1)  All commercial airplane flight requires a minimum of 2 pilots.  Crew Resource Management (CRM) procedures were introduced into the entire worldwide industry following crashes where the pilot made a decision and the co-pilot dared not challenge it.  CRM gives procedures and authority to question the pilots decision and take control.  CRM is taught to every cockpit member in the manner that there will be questionable decisions by the pilot-in-command and it is the obligation of the crew to validate or alter the decision activity.

 

2)  Aircraft have built in systems such as Ground Proximity Warning System to provide notice in the event an incorrect decision on flight path when near the ground.  The pilot still has the control authority.  Nearly all aircraft systems also have built in CAS notification (Caution Advisory System) in the event certain selections, faults or failures occur that "could" lead to a hazardous situation.

 

Aircraft simulators interject both equipment fault and decision conditions as above and react negatively when the wrong decisions are implemented.  This is an excellent teaching tool, because the pilots generally file this situaton away in memory; and are coached to make more appropriate choices (i.e. sometimes there are several possibilities that will correct the situation).

 

from  my 50 yrs. of aviation background, I have watched all of this be implemented - over time!  From this experience is what drives me to believe getting the Diagnostic Team functioning together (using the combined intellectual resources and experience) will lead to the quickest payback to improving patient's diagnostic result.

 

I have found that this is no small feat as there are a lot of factors working in the opposite direction:

·         Clinician desire for autonomy - culture

·         Payer system

·         Radioligist/Pathologist goal to maximize cases reviewed in a shift - no time for discussion

·         High percentage of cases of on target diagnosis leading to patient recovery

·         Patient inability to question the early conclusions

·         and on and on

 

Fortunately, there are some hospital systems out there that are trying to find a method to get Diagnostic CRM to function in the manner needed.  There are many thousands of clinicians and staff that have been trained in TEAMSTEPPS (which works in the Team direction) for surgery and other functions.  I am puzzled why it hasn't trickled down to the Diagnostic area.

 

   Nelson

 

TAMARAC LLC

860-844-0199

 <mailto:ntoussaint at tamarac.com> ntoussaint at tamarac.com

 

From: Robert Bell [mailto:rmsbell200 at yahoo.com] 
Sent: Wednesday, January 23, 2019 12:01 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG; Nelson Toussaint
Subject: Re: [IMPROVEDX] how to teach about cognitive bias

 

Very interesting discussion.

 

Is bias considered in air pilot simulation training? How do they include that? 

 

Does the airline industry believe that simulation training would be useful in medicine?

 

Rob Bell

 

On Tuesday, January 22, 2019, 9:43:18 PM MST, Nelson Toussaint <ntoussaint at TAMARAC.COM> wrote: 

 

 

 

 

October 5, 2015

9:30 PM

 

Last summer, I had an opportunity to tour the Hartford HealthCare CESI Lab where there is a lot of Simulation in action.  They also have an operator that can interject scenario issues to provide unexpected patient responses to clinicians during the activity to help them deal with abnormal conditions.  I believe this is mainly teaching surgery functions at this time.

 

   Nelson Toussaint

 

TAMARAC LLC

860-844-0199

 <mailto:ntoussaint at tamarac.com> ntoussaint at tamarac.com

 

 

From: Sherrill Franklin [mailto:sfranklin131 at GMAIL.COM] 
Sent: Sunday, January 20, 2019 5:48 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] how to teach about cognitive bias

 

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://news.wisc.edu/flight-simulator-for-surgeons-project-joins-computer-science-with-medicine

 

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> 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> 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> 
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)
 <mailto:Lorie.Slass at ImproveDiagnosis.org> Lorie.Slass at ImproveDiagnosis.org
Phone: 215.801.4057
 <http://www.improvediagnosis.org/> www.improvediagnosis.org 
<image001.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
 <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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