how to teach about cognitive bias

Mark Graber Mark.Graber at IMPROVEDIAGNOSIS.ORG
Thu Jan 24 18:27:31 UTC 2019


Hi David,

We can all certainly appreciate the ‘brittle’ elements inherent in the Columbia and Challenger incidents, but we need to discuss the importance of the ‘erratic components such as people’ as it applies to the drink-bag incident, and comparable breakdowns in medical diagnosis.

An incident with many parallels is the misdiagnosis of Thomas Eric Duncan<https://www.degruyter.com/view/j/dx.2014.1.issue-4/dx-2014-0064/dx-2014-0064.xml>, the first patient with Ebola infection in the US.  So in both situations the active players were confronted with a novel situation that was initially misdiagnosed.  The question for all of us in the diagnostic error world is whether there is any chance to improve the human-performance element to improve the odds these kinds of situations will be handled more appropriately in the future, given all the ‘brittle’ elements of our work environment that exist (and could\should be addressed separately).  In other words, what if Luca and the NASA team had actually employed the STAR approach and pondered ‘what else’ could have been responsible for the water accumulation besides a reflux from the drink bag?  Or in the case of Mr Duncan, what else could have accounted for his presenting symptoms?   In both cases the situation was one the sharp-end team had never encountered, but adopting a decision-making strategy to consider alternatives could conceivably have been effective in leading to better solutions, no?  I am not discounting the interplay of the many system-related issues in both cases that could also have facilitated solutions, but that’s a separate discussion.

Are we wasting our time thinking that its possible to improve decision-making?

Mark

From: "Woods, David" <woods.2 at osu.edu>
Date: Thursday, January 24, 2019 at 5:11 AM
To: Mark Graber <Mark.Graber at Improvediagnosis.org>
Cc: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] how to teach about cognitive bias

Sorry Mark

Your comment is a profound misunderstanding of the space shuttle accidents and the spacewalk near miss, and the struggles of NASA as any working organization to deal with a variety of pressures, uncertainties and risks.  I was an advisor to the Columbia board and you can see the organizational factors and production pressure in chapter 6 of the board’s report  (or see my chapter from 2005 or testimony to congress on it with respect to the need to develop Resilience Engineering in 2003 — NASA accidents in 1999 were the original stimulus to start the work to build  Resilience Engineering).  [links below] As Reason 97 book emphasizes and these events illustrate, these are organizational accidents. As I conclude, in reviewing findings on safety in complex systems since,  “failure is due to brittle systems, not erratic components such as people."

My colleagues have been helping NASA struggle with learning from the space walk near miss and my team uses the case as a role play workshop on how to balance production pressure with safety risks — the sacrifice judgment (see the original Essentials of Resilience chapter in 2006 which includes and refers to health care examples).  We will be running the role play based on the spacewalk mishap again at the end of February (all day Feb 27th) with NASA participation, if the government shutdown ends in time.  People get to confront risk and trade-offs as they are embedded in uncertain information about an evolving situation in roles such as the Flight Director perspective. The Sacrifice Decision Workshop also includes a walkthrough of the Oroville Dam near miss — on the surface a completely different world but together the events illustrate deeper fundamentals.  People can come just to the 1 day Sacrifice Decision Workshop or stay for the other parts of the 3 day meeting on Safety II.   https://www.safety-ii.com/about/     There are other parts of the program with health care connections.

David

In addition, though further away, we are running the 8th Biennial International Symposium on Resilience Engineering in Kalmar Sweden, June 24-27, 2019.  The program will deal with a variety of fundamentals findings and practical efforts on safety, resilience, and  complexity across sectors.


 [Also note NASA accidents and significant near misses generate independent investigations — contrast Columbia and Duke Hospitals' Jesica Santillian transplant death a couple months apart in early 2003 — NASA had a public independent review focusing on organizational issues which led to widespread organizational changes while public information on Duke's accident was press releases vetted by lawyers about a revised form.]

https://www.researchgate.net/publication/237353911_Creating_Foresight_How_Resilience_Engineering_Can_Transform_NASA%27s_Approach_to_Risky_Decision_Making
https://www.researchgate.net/publication/255648297_Creating_Foresight_Lessons_for_Enhancing_Resilience_from_Columbia
https://www.researchgate.net/publication/284328979_Essential_characteristics_of_resilience


David Woods
Releasing the Adaptive Power of Human Systems

follow @ddwoods2<https://twitter.com/ddwoods2>

Professor
Department of Integrated Systems Engineering
The Ohio State University

Past-President
Resilience Engineering Association
Human Factors and Ergonomics Society

woods.2 at osu dot edu
614-946-0123

SNAFU Catchers Consortium, see results at
 stella.report <https://drive.google.com/file/d/0B7kFkt5WxLeDTml5cTFsWXFCb1U/view>  or video intro at  http://bit.ly/StellaReportVelocity2017

keynote on autonomy and people see
part 1: https://youtu.be/b8xEpjW0Sqk   part 2: https://youtu.be/as0LipGTm5s  part 3: https://youtu.be/2GEsxMuLWIE

keynotes on resilience and complexity see
https://www.youtube.com/watch?v=7STcaWjJoww&index=7&list=PL055Epbe6d5YDU6sikjqcd_YM9XT4OehD
or
https://www.youtube.com/watch?v=zHJdDMQJXiw&index=8&list=PL7_JAXDeVTvIZ_Y-ddqCiGF-ZKxtM5MLe

on the Strategic Agility Gap
https://drive.google.com/open?id=1ISBZPkxxEvEt4mCAiJaarxQ1umwDYUld








On Jan 23, 2019, at 5:44 PM, Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at improvediagnosis.org>> wrote:

Probably no one (maybe the CIA?) has thought more about the cognitive bias problem than NASA.  Cognitive errors were at the root of both the Challenger and Columbia disasters, for instance. There was also a fascinating case study of an incident aboard the International Space Station that was really just a (near fatal) diagnostic error, like the ones we see:  Astronaut Luca Parmitano experience water accumulating in his helmet during an extra-vehicular activity that was attributed to his inadvertently squeezing the ‘drink bag’ on the front of his space suit; no harm done.  The next week during another EVA, water again began filling up his helmet, this time to the point that he was near asphyxiation before he could return to the interior of the station. The real problem was not the drink bag at all, as initially diagnosed, but a faulty water-recirculation unit in the suit.

NASA has devoted considerable attention to the decision-making process that they employ as an organization, and they rely very extensively on normative decision-making whenever possible. But they also recognize “System 1” will come into play in daily activities.  Astronaut training therefore includes modules on decision-making that explore the dual-process model.  In their Space Flight Resource Manual, decision-making heavily emphasizes the use of group involvement (Crew Resource Management), but also provides advice for the individual, which they term the STAR model.  (See Below).  Looks pretty similar to our advice in medicine to avoid System 1 errors:  Stop and Think !    NASA also provides to their astronaut trainees very extensive training opportunities (many under adverse conditions) that include decision-making as part of the activity.

A few years ago, SIDM received a very small grant from NASA to review their decision-making process and make recommendations.  The report is buried somewhere on their website, but I’d be happy to provide excerpts to anyone interested.

     Mark

Mark L Graber MD FACP
Chief Medical Officer; Founder and President Emeritus, SIDM
Professor Emeritus, Stony Brook University, NY
<image001.jpg>

<image002.png>
From: Sherrill Franklin <sfranklin131 at GMAIL.COM<mailto:sfranklin131 at gmail.com>>
Reply-To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>>, Sherrill Franklin <sfranklin131 at GMAIL.COM<mailto:sfranklin131 at gmail.com>>
Date: Wednesday, January 23, 2019 at 7:53 AM
To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at list.improvediagnosis.org>>
Subject: Re: [IMPROVEDX] how to teach about cognitive bias

Rob,

I’m not sure if the aviation industry as a whole recommends cognitive bias training for the medical profession, but “Sully Sullenberger” of landing-on-the Hudson-fame is an advocate for patient safety in this article in Stanford Medicine<https://med.stanford.edu/news/all-news/one-to-one/2012/sully-sullenberger-takes-on-patient-safety.html>.

Also--

I found this cognitive training report for pilots. Perhaps training materials could be adapted for physicians and other health care providers.  Full PDF is attached at the end.
1.1 Key Findings
* Aeronautical Decision Making (ADM) can be taught both in a classroom and a simulator environment. The principles and concepts of ADM have been accepted and used by a wide variety of civil and military aircraft users performing a multitude of missions.
* All formalized ADM training seems to improve safety through significant reductions in Human Performance Error accident rates.
* These widespread successes have generated a need for second generation ADM training materials for use in recurrency training and to more adequately address the cognitive processing needs of experienced pilots.
t The NTSB has recommended that the FAA pursue the implementation of ADM more vigorously following a fatal accident between an airplane and a helicopter in April 1991.
* Expert cognitive performance is characterized by rapid access to a well organized body of conceptual and procedural knowledge. This is a modifiable information structure based upon knowledge that is experienced. This experience allows the perception of large meaningful patterns in familiar and new situations which help the expert match goals to task demands. This means they can respond creatively or with opportunistic solutions based upon a global perception of the meaningful relationships in a situation.
 Experienced pilots have exhibited expert cognitive performance through keen, quick, confident decisions and almost a direct perception of the proper course of action. These decisions occur so rapidly it appears to be acognitive process and behavioral resultant based upon insight or intuition. This intuitive performance is based upon: experience (cognitive and sensory, internal and external); the cues and context of the situation; and, the expert's ability to identify causal relationships in a situation.
* The development of these expert pilot cognitive processes can be correlated with the growth in other aviator skills which result from training and experience. The ability to develop a second generation of ADM mateinals to teach or train these skills will require a more thorough understanding of how experts use past experience to assess new situations, make decisions and define goals.
* The expert pilot is adaptive. He/she can perceive the necessity to alter (or not to alter) ingrained conceptual and procedural knowledge based upon the parameters and dynamics (cues and context) of the problem or situation encountered.
* Experiencing situations repeatedly throughout an aviation career enhances a pilot's cognitive processing by providing reinforcement of knowledge to apply to similar new situations, by providing more associative paths to speed-up recall of knowledge and by providing elaborations on previous situations which can be used for both recall and inference.
* Experience can also interfere with the perception of a situation and provide negative reinforcement for later use in bad decision making. Job or personal stress, anxiety, fixation, emotional blocking, etc. will affect the stored knowledge negatively and it will not be usable in new situations.
* Experience or training that is intended to be used for the development of expert pilot cognitive processing development must insure the perception of the essential psycho physiological elements of the problem. The appropriateness experience will be critical to the subjective associations and stored knowledge patterns that will be used in new situations.

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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 23, 2019, at 12:01 AM, Robert Bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

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<mailto: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

ntoussaint at tamarac.com<mailto: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<mailto: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<mailto: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<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&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)
Lorie.Slass at ImproveDiagnosis.org<mailto:Lorie.Slass at ImproveDiagnosis.org>
Phone: 215.801.4057
www.improvediagnosis.org<http://www.improvediagnosis.org/>
<image001.jpg>


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
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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