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© 2006 Wotkyns Creative Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014 ognitive Error in Medicine Thinking like Sherlock
© 2006 Wotkyns Creative
Dennis J. Boyle, MDDenver Health/UCDSOMCOPIC2014
Cognitive Error in MedicineThinking like Sherlock
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Outline
Scope of the problem
How we diagnose
Examples
Improving the process
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The diagnosis is every doctor's measure of his own abilities and is the most important ingredient of his self-image
Nuland 1994
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The death of one man is a tragedy The death of millions is a statistic Stalin
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The death of one man is a tragedy The death of millions is a statistic Stalin
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80,000 deaths a year
Leape JAMA 2002
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So what is a diagnostic error?
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What is a diagnostic error?
A missed or delayed opportunity to make a timely diagnosis
Singh JAMA IM 2013
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Diagnostic error is divided into cognitive and systems. Today we will look at cognitive…
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Cognitive error is different
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Cognitive error is complex…
Evolving/NYD
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Evolving/NYD
Pt issues
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Complex…
Evolving/NYD
Pt issues
System issues
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Complex…
Evolving/NYD
Pt issues
System issues
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Complex…
Evolving/NYD
Pt issues
System issues
WHO 12,420 diseases
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Complex…
Error rate
80% of charts no diff DX
54% feel they make one error/month
Rad/Path rate 2%
IM rate 10 – 15%
1/1000 outpatient visits
Singh 2013 Graber Am Jmed 2008 Arthur Elstein
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Error results in……
#1 cause of lawsuits
Overtreatment
Emotional impact
Wasted money and time
Gelhart NEJM 2009
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Can we afford to be perfect- breast imaging
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And cognitive errors occur because….
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But it’s still complicated…..A stroke alert story
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But it’s still complicated…..A stroke alert story
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How we think - System I vs. System II
Kahneman and Tvertsky
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How we think - System I vs. System II
Kahneman and Tvertsky
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How we think - System I vs. System II
Kahneman and Tvertsky
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Where does this all happen?
Lehrer J How we decide. 2009
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Thin slicing - Separating wheat and chaff
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Blink
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Where is the lesion?
Blink
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Blink
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Where was the lesion?
System I - Blink
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System II - Hypothetico-deductive style
Rigorous
List all possibilities
Probabilistic
Occurs in prefrontal cortex
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System II- Hypothetico-deductive style
Problem list
Lower GI symptoms
Arthralgias
High ESR
Low vitamin D
Low back pain
Osteoporosis
J Hirsh 2011
Differential DX
Sprue
Reactive arthritis
Colitis w Spondy
Vasculitis-PAN
Fibromyalgia/ IBS w another cause of ESR
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How much time do you spend in system I
20%
50%
75%
95%
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How much time do you spend in system I
95%
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The brain is a cognitive miser
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Toggle function system I and II
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Stress and fatigue push us to system I
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The problem with System I is biases – name the bias
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Anchoring bias - rely on first impressionPremature closure – decide too early
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Last 2 patients had flu - Availability bias – what comes to mind
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Affection bias – taking care of loved ones Evolving - NYD
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Framing bias – how it’s presented
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I’ve got this pt I’d like you to see.
She’s a psych patient with CP…..
He’s a drunk with abdominal pain
Mcneil NEJM 1982
Fast track patient with a cold
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Anchoring and framing biases
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At sign out knee trauma F/U US
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Framing and premature closure
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Where is the lesion?
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Search satisficing - Stop the diagnostic process once one diagnosis has been made-
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December 2000
Ten Years Later
Ten Years Later
Alliteration bias – previous errors
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Anchoring bias is the big kahuna……
Top 10 fixes for diagnostic errors
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#10 Reflective listening and build a story
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#10 75% of the DX comes from the HX
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#9 Mindfulness - reflective practice
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#8 Build your knowledge base
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#8 And try to figure it out
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#7 Always do a differential
Problem list
Lower GI symptoms
Arthralgias
High ESR
Low vitamin D
Low back pain
Osteoporosis
J Hirsh 2011
Differential DX
Sprue
Reactive arthritis
Colitis w Spondy
Vasculitis-PAN
Fibromyalgia/ IBS w another cause of ESR
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#6 Use your Bayes A 63 YO w CP and DM ? treadmill
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#5 Use Occams razor
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#4 IT –the original tricorder…think Amazon...
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18 hour w/o sleep = ETOH 0.05%
And when you’re behind, tired or overloaded….
Beer pic
#3- Be aware of stress
#2 – Always ask what else could this be?
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#1 Think like Sherlock
Sherlock clip
Manede Psych res 2010
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So what do I do?
If you’re sure
What else could it be ?
If You’re not - NYD
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So what do I do?
If you’re sure
If You’re not - NYD
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Think like Sherlock!
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Homework for all of us!!!
If you’re sure
What else could it be ?
If You’re not - NYD
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Think like Sherlock!
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The problem is not knowledge but thinking. Can improve your diagnosing?
Dennis Boyle [email protected]
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