Dual Process and Cognitive Bias in Clinical Decision Making

Joan M. Von Feldt, MD, MSEdProfessor of Medicine

vonfeldt@mail.med.upenn.edu

Thinking Fast and SlowDaniel Kahneman

Heuristics and Biases

Thin Slicing

RecognitionPrimed

Deliberationwithout attention

Modularresponsivity

Gestalt effect

Inductivereasoning

Hypothetico-deductivereasoning

RobustDecisionMaking

Normativereasoning

ExhaustionStrategy

Boundedrationality

Bayesianreasoning

Approaches to Decision Making

Intuitive Analytical

Croskerry. Adv in Health Sci Ed 2009; 14:27-35

System I (Intuitive)

System II(Analytical)

Cognitive Style Heuristic Systematic

Cognitive Awareness Low High

Automaticity High Low

Rate Fast Slow

Effort Low High

Emotional Component High Low

Scientific Rigor Low High

Errors More Less

Properties of the 2 types of decision-making

Examples: System 1 & 2 Thinking

Your route to work

An out of town guest staying with you who

will meet you at your work

Your route to work after being away for 20

years or major road work

Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract. 2009 Sep;14 Suppl 1:27-35.

Model for diagnostic reasoning based on pattern recognition and dual-process theory

Heuristics

Pattern Recognition Illness Scripts Gestalt Instance Scripts i.e “Blink”; “Thinking Fast”

Heuristics

Can be good: » provide cognitive “short cuts” in the face of complex

situations» Help us to be efficient

Can be bad:» They tend to be thinking traps – so beware!» Can adversely influence our diagnostic decisions

Croskerry, P. Acad Med 2003; 78:775-80.

Institute of Medicine Report Published in 1999

Addressed the problem of preventable medical errors

Charged the healthcare industry to evaluate and change their systems to prevent patient harm

Systems Errors: Complicated

Cognitive Errors: Just As Complicated…But In A Different Way

Cognitive Error Categories

Faulty Knowledge

Faulty Data Gathering

Faulty Information Processing

Faulty Verification

Origins of diagnostic error in 100 patients

Leape LL, et al. N Engl J Med 1991; 324(6): 377-84.

Graber ML. Franklin N. Gordon R. Diagnostic error in internal medicine. Archives of Internal Medicine, 2005; 165(13): 1493-9.

19% related to Systems

Error28% related to Cognitive

Error46% related

to both Systems and Cognitive

Errors

Forgot to f/u on the blood cultures…

Poor communication among consultants…..

Didn’t expand your differential diagnosis…..

Anchoring Bias

Also called “premature closure”

the failure to continue considering reasonable alternatives after a primary diagnosis is reached, is the most common diagnostic error

ie When the diagnosis is made, the thinking stops

Croskerry, P. Acad Med 2003; 78:775-80.

Confirmation Bias

Confirmation bias

Tendency to look for confirming evidence to support a diagnosis rather than look for discomfirming evidence to refute it (despite the latter often being more persuasive and definitive)

Absolutely!

Croskerry, P. Acad Med 2003; 78:775-80.

Availability

Availability bias

Judge things as being more likely if they readily come to mind

Croskerry, P. Acad Med 2003; 78:775-80.

Unpacking Principle

The failure to elicit all relevant information in establishing a differential diagnosis that may result in significant possibilities being missed

Croskerry, P. Acad Med 2003; 78:775-80.

Framing Effect

The framing of the patient scenario, including the source and where the patient is seen, influences the way the patient is thought about

Croskerry, P. Acad Med 2003; 78:775-80

Diagnosis Momentum

Also known as “chart-lore”- once diagnostic labels are attached to patients, they become stickier and stickier

Croskerry, P. Acad Med 2003; 78:775-80.

Visceral Bias

Counter-transference negative feelings towards a

patient may result in diagnoses being missed

Common Types» Non-compliant patients» Homeless patients» Patients with chronic pain» Obese patients

Cognitive Bias Can Lead to Errors in Diagnosis

How Do We Deconstruct Our “Brick Walls”?

5 Basic Questions to Help Avoid Cognitive Errors

What are traps I might fall into

What else can it be?

Is there anything that doesn’t fit?

Is there’s more than one thing going on?

Is this a case where I need to “slow down”?

Summary

Heuristics are important for efficiency of care Heuristics can also be used for expediency of care

that may compromise optimum care Cognitive bias is an important factor that can

adversely influence diagnostics Thorough problem lists and broad differentials can

mitigate some cognitive bias MD 305 rule: Minimum of 3 diagnoses, 2 organ

systems

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