Diagnostic Error: Rethinking Our Relationship - PowerPoint Presentation

Slide1

Diagnostic Error: Rethinking Our Relationship to Wrongness

John Banja, PhD

Center For Ethics

Emory University

jbanja@emory.eduSlide2

Why Be Interested in Diagnostic Error?

Diagnostic errors are the leading cause of medical malpractice suits: 45% of cases

Physicians profoundly underestimate their rates of diagnostic errors: What do you think yours is?

Health systems unappreciative of the problemSlide3

Common DE Scenarios

Dr. Banja examines a patient but:

Fails to order a diagnostic test that 99 out of 100 physicians would say he should have ordered (or he orders a wrong/irrelevant test)

Orders a correct diagnostic test but the test is never performed (or it is performed but the results are lost)

Orders a diagnostic test, the test is performed, but Banja never reads the results (or learns the results too late because the findings are lost or delayed)

Orders the diagnostic test, it is performed, Banja reads the results, but fails to appreciate their implications; because of that he fails to develop an appropriate treatment plan, saying instead, “You’re fine, Mrs. Smith. Nothing to worry about.”Slide4

Diagnostic errors are unappreciated because:

We have very poor feedback mechanisms that fail to alert physicians to diagnostic errors and their rates

Many patients have self-limiting ailments from which they recover despite diagnostic error

Sometimes the diagnosis is wrong but the treatment is nevertheless curative; alternatively, sometimes you don’t have to make the correct diagnosis for the patient to get appropriate care

Patient sees another physician who makes the correct diagnosis and treats accordingly

Patient dies from diagnostic error and the erring physician never learns about itSlide5

Strategies to reduce DEs

Metacognitive training/failed heuristics

Computer based decision supports

AutopsiesImproving systems (test ordering, specimen processing, test performance, interpretation, follow-up, poor standardization of processes)

Better feedback processes

More patient involvement

Better medical education

Better history and physical examination Slide6

The goal: “To rethink our relationship to wrongness.”(p.121) Slide7

Leon

Festinger

: Cognitive Dissonance

CD is an uncomfortable feeling caused by holding two contradictory ideas simultaneously;

What happens when a very deep-seated belief is disconfirmed by new data?Slide8

The Problem of Ideological TransformationSlide9
Slide10

Mark

Bertolini

, the unconventional chief executive  of Aetna, the health insurer, gave thousands of the lowest-paid employees a 33 percent raise, and he has introduced popular yoga classes. His discussions were influenced, in part, by a near-fatal ski accident. Slide11

Fundamental Beliefs are …

Our navigational tools

Make meaning and sense of our experiences and the world

Provide the most basic and fundamental directions for our beliefs, feelings, and behaviorsSlide12

THEY ARE PROFOUNDLY SELF-DEFINING!Slide13

And this is the Self Professionals Want

PROFESSIONAL

SELF

Adequate

Competent

Useful

Informed

In control

Assured

Powerful

AwesomeSlide14

But this professional self is under constant attack!Slide15

The Remarkably Imperfect

Human Being

Human cognition is

re-markably fallible: slips, lapses, mistakes,

unintentional as well as intentional

variations of standard

processes, faulty reasoning, prone to implementing biases (e.g., availability, confirmation, anchoring, etc.) leading to error, etc. Slide16

Here’s an exampleSlide17

TEST QUESTION

A baseball bat and a baseball together cost $1.10.

The bat costs $1 more than the ball.

How much does each item cost? Slide18

The question …..

Was circulated among undergraduates at Ivy League Universities and at Public Universities:

~ 50% of the IVY League students got it wrong.

> 50% of the Public University students got it wrong.Slide19

Once again…

A baseball bat and a baseball together cost $1.10.

The bat costs $1 more than the ball.

How much does each item cost? Slide20

The correct answer is….

The bat costs $1.05

The ball costs $.05

If you said the bat costs $1.00 and the ball costs $.10, then the bat would cost $.90 more than the ball. But you were told the bat costs $1 more.Slide21

Add to that the Degraded Work Environment

Work area design

Faulty communication

New or unfamiliar procedures

Multi-tasking

Shift work fatigue

Constant interruptions

Phone calls

Pre-occupation

Need to hurry

Long waits to be seen

Dim lighting

Noise

Many sick patients

Home stress

Uncertain expectations

Violence

Short-staffed

Multi-tasking

Technology won’t work

Ambiguity

New trainees

Hunger

Taking short cuts

Conflicting priorities

Unworkable policiesSlide22

And not only that but……

Unpredictable and dynamic environments

Multiple sources of concurrent information (with varying accuracies)

Reliance on indirect or inferred indications (e.g., judgment calls)

Actions having multiple consequences

High stress

Complex human to machine interfaces

Multiple players with varying levels of competence and familiarity

High stakes that may compromise risk awareness and risk

aversivenessSlide23

And add to that…..

“Do you people really know what you’re doing here?”

“I’ve got WHAT?????”

“Are you licensed?”

“Let me tell you something….”

“Oh God, this can’t be happening to me….”

“Oh, I hurt so much…why can’t you do something?”

“How much time do I have?”Slide24

Feelings, feelings, feelings…..

“Our first response to anything is an affective one that governs the future direction of our relations.” (

Croskerry

, 2008a)Slide25
Slide26

“[V]irtually every image, actually perceived or recalled, is accompanied by some reaction from the apparatus of emotion.” (58)

“[E]ven when we “merely” think about an object, we tend to reconstruct memories not just of a shape or color but also of the…accompanying emotional reactions, regardless of how slight…You simply cannot escape the

affectation

of your organism, motor and emotional most of all, that is part and parcel of having a mind.” (FWH, 148) Slide27
Slide28

How is John doing?Slide29

Feelings, feelings, feelings…..

“Our first response to anything is an affective one that governs the future direction of our

relations

behaviors.” (

Croskerry

, 2008a)Slide30

Application to Diagnostic ErrorSlide31

The goal: “To rethink our relationship to wrongness.” (p.121) Slide32

The Encounter With Uncertainty in a Clinical Context

Behavioral

: Stymied, paralyzed, incapacitated, unable to move forward;

Cognitive: Cannot assign outcome probabilities confidently; cannot plan or envision a course of action or a treatment plan;

Affective

: Anxiety, feeling lost, helpless, disoriented, etc. Slide33

“It is considered a weakness and a sign of vulnerability for clinicians to appear unsure. Confidence is valued over uncertainty, and there is a prevailing censure against disclosing uncertainty to patients.”

Croskerry

2008b)Slide34

The Professional Self

PROFESSIONAL

SELF

Adequate

Competent

Useful

Informed

In control

Assured

Powerful

AwesomeSlide35

The Professional Self Under

the Assault of Uncertainty

Humiliated

Shattered

Coming Apart

Inadequate

Incompetent

Nonuseful

Stupid

Not in control

Disoriented

Powerless

WorthlessSlide36

Antidote: Overconfidence

“Overconfidence results at times from a

desire to see the self as a competent or accurate perceiver

…undue confidence often arises when uncertainty would

challenge valued beliefs about the self as knowledgeable and competent

…the motive to see the self as competent leads to

less critical analyses

of the true ability levels during confidence assessments…our participants were

motivated to protect themselves from the implications of feeling uncertain.”

(Blanton, 2001)

“

Most efforts to reduce overconfidence have failed

.” (

Arkes

,

1987)Slide37

Me? Screw Up? Get outta here..

“Overconfidence can impart a false sense of security” (Bauman, 1991)

When Graber asked physicians whether they made a diagnostic error in the past year, only 1% admitted it. “

The concept that they, personally, could err at a significant rate is inconceivable to most physicians

….Physicians acknowledge the possibility of error, but believe that mistakes are made by others.” (

Berner

, 2008)Slide38

The Fundamental Problem of Overconfidence

Overconfidence becomes a replacement or substitute for failing to look for more evidence, for not seeking more feedback, etc.

Instead of accepting my uncertainty and managing it constructively, I resist it and compensate for it by cultivating powerful feelings of being right that soothe my self-esteem. Slide39

Overconfidence and the Pragmatics of Medicine

Humans are

not Bayesian thinkers

, but have evolved (fast and frugal) cognitive biases for reasons of neurological efficiency (biological mutations were easier to produce), response speed, and the adaptive challenges in the survival landscape.

Biases allow agents to make effective (i.e., uncostly, adaptive) decisions with less information

Fast and frugal

decisionmaking

“

succeed so reliably

that physicians can become complacent; the failure rate is minimal and errors may not come to their attention for a variety of reasons.” (

Berner

, 2008)

The more knowledgeable I feel myself to be, the less I rely on decisional aides

“Flawless intellectual reasoning, diligent checking for errors and foolproof environmental safeguarding would require

superhuman talent

.” (

Redelmeier

,

2001)Slide40

And the longer you are in practice…

“Physicians with many years of clinical practice may be even more susceptible to availability bias than second-year residents.” (

Mamede

, 2010)“Increased experience was associated with decreased likelihood of requesting second opinions, curbside consultations, and reference materials, regardless of diagnostic accuracy.” (Meyer, 2013)Slide41

So, is this physician overconfident?

No: not so long as his clinical discernment and judgment are “reasonable,” i.e., comply with the professional standard.

Also: When you hear the sound of hooves….etc. Slide42

The Problem is when….

That nagging feeling of uncertainty enters the picture

The question: When should I get support/help:

Metacognitive training/failed heuristics? (Am I in denial? Rationalizing?)

Computer based decision

supports?

Autopsy?

Do homework on this one?

Greater skill development? (Improving history and physical? Improving test interpretation or following) Slide43
Slide44

Poor Feedback Increased Confidence

“In the absence of … clear feedback, physicians feel little need to update their current Diagnostic Schema. Thus a felt need for Updating declines and Confidence increases. As Confidence increases the felt need for Updating decreases further in a reinforcing cycle.” (Rudolph, 2008) Slide45

Changing the deep-seated beliefs and practices may require divine intervention

“Physicians are slowly being convinced that fallibility is the human condition, and most readily acknowledge slips and lapses, but seasoned practitioners have lingering doubts that their own reasoning could be flawed…[R]

estatement

of compelling evidence has never been a sufficient force to change established clinician behavior

…

change

may represent a midbrain event more than a cortical event

.” (Miles, 2007)

“[D]

ebiasing

will probably require multiple interventions and lifelong maintenance.” (

Croskerry

, 2013)Slide46
Slide47

Unhealthy Humility Prototype

Servility

Obsequiousness

GrovelingLow self-esteemFeelings of shameA brake on immoderate ambition (Thomas Aquinas)

Bernard (“On Humility and Pride”):

Quiet and restrained speech

Keeping silent unless asked to speak

Thinking oneself unworthy to take initiative

Desiring no freedom to exercise one’s will Slide48

“Healthy” Humility Prototype, i.e., Optimal Self-Calibration

Accurate self-opinion (doesn’t distort self-information for narcissistic needs)

Keeping one’s talents in perspective

Self-acceptance and understanding one’s imperfections; no need to see myself as superior

Freedom from arrogance

Freedom from low self-esteem

Willingness to admit mistakes

Contrition for one’s shortcomings

Lack of (and relief from) self-focus and self-preoccupation

Able to recognize importance and significance of others

Self-forgetfulness

Lack of regard for social statusSlide49

“Rethinking our Relationship

to Wrongness” and Mid-Brain Changes

Acknowledge lack of feedback mechanisms

Accept importance

of diagnostic error

Actively discuss

diagnostic challenges

Discuss diagnostic error

early

in the education of medical students

Allow medical students and residents to

openly question

diagnostic decisions, verbalize their own diagnostic reasoning, and receive constructive feedback

Ask “What do I not want to miss?”

Implement a system to

automatically screen

patients returning to the ED within 48 hours

Special consideration for symptom presentations at

elevated risk

for errorSlide50

Diagnostic Error (Humility) Measures from the Pennsylvania Safety Authority (25A)

Request second opinions

Request diagnostic feedback from colleagues

Notify referring physicians when diagnoses of referral patients are modified

Disclose diagnosis to patients

early, then refine/modify

with patient involvement

Survey past patients

to see if diagnostic error occurred

Educate and involve patients

in the diagnostic process

Create

reliable feedback loops

Monitor diagnostic error ratesSlide51

Humility Strategies

“…openness toward reflection that would allow for

better toleration of uncertainty

… making error visible…provide expert consultations.” (Berner, 2008)“[T]he motive to boost confidence may be attenuated if a person is first given opportunities to

lower the importance of feeling knowledgeable

.” (Blanton, 2001)

“[O]ur participants were motivated to protect themselves from the implications of feeling uncertain...

one of the best ways to decrease overconfidence may be to decrease the threat inherent in admitting ignorance

.” (Blanton, 2001) Slide52

Looking for humility in medicine: Jennifer Arnold, MD

Born with skeletal dysplasia (

spondyloepiphyseal

dysplasia)Has undergone >30 surgeriesMD graduate from Hopkins in 2000; board certified in pediatric and neonatal medicineSlide53
Slide54

Arnold on Humility (Commencement Speech to the MD Graduates at UTMB Galveston 2012)

“[A]

cademic

medicine and the media support arrogance, assertiveness, and even entitlement. As a medical student you had to overcome numerous intellectual, emotional, social and economic challenges to become a physician. The hidden curriculum of medical education promotes egoism, “I paid my dues, so now I am entitled to….” We are surrounded by personifications of physicians in the media that promote this as well. Television and film promote doctors who know it all (

House, MD

) or who are sexy, self-confident, and always take charge in the operating room (

Grey’s Anatomy

). Patients come to you looking for answers, treatment, expertise, and even miracles. Yet, when we don’t know all the answers we are afraid to admit to our limitations.”Slide55

Factors militating against humility

“[W]e propose that humility would be unlikely to stem from parenting or educational styles that involve (a) an extreme emphasis on performance, appearance, popularity, or other external sources of self-evaluation, particularly if combined with perfectionist performance standards; (b) inaccurate, excessive praise or criticism; (c) frequent comparison of the child against siblings or peers, especially if this comparison is accompanied by competitive messages; and (d) communicating to the child that he or she is superior or inferior to other people. Such practices would predispose a child to turn to external sources of validation for a sense of security, and they would also encourage the child to make competitive, invidious comparisons.” (Peterson, 2004) Slide56

Fostering Humility: How difficult it is

Exposure to different peoples and cultures

Life threatening illness

Serious accident

Birth of a child

Dissolution of a marriage

Religious beliefs

Transcendental experiencesSlide57

Future directions and challenges

In what specific domains is a sense of humility adaptive and by what mechanisms?

Are there circumstances in which humility can be a liability?

How can parents, teachers, and therapists foster an adaptive sense of humility?Slide58

“The difference between the expert and the amateur consists in the fact that when the expert commits error, he or she is often able to make an heroic recovery.” (James Reason, Human Error.)Slide59

The goal: “To rethink our relationship to wrongness. (121)” Slide60
Slide61

ReferencesSlide62

References

Arkes

, H.R., et al. 1987. Two methods of reducing overconfidence. Organizational Behavior and Human Decision Processes, 39, 133-144.

Baumann, A.O., et al. 1991. Overconfidence among physicians and nurses: the micro-certainty, macro-uncertainty phenomenon. Social Science Medicine, 32(2):167-174.

Berner

, E.S., and M.L. Graber. 2008. Overconfidence as a cause of diagnostic error in medicine. American Journal of Medicine, 121(5A):S2-S23.

Blanton, H., et al. 2001. Overconfidence as dissonance reduction. Journal of Experimental Social Psychology, 37:373-385.

Croskerry

, P. 2013. from mindless to mindful practice—cognitive bias and clinical decision making. New England Journal of Medicine, 368(26):2445-2448.

Croskerry

, P., A.A.

Abbass

, A.W. Wu. 2008a. How doctors feel: affective issues in patients’ safety. The Lancet, 372: 1205-1206.

Croskerry

, P., and G. Norman. 2008b. Overconfidence in clinical decision making. American Journal of Medicine, 121, (5A):S24-S29.

Damasio

, A. 1999. The Feeling of What Happens. New York: Harcourt Brace and Company.

Ende

, J. 1983. Feedback in clinical medical education. JAMA, 250(6):777-781.

Graber, M.L., N. Franklin, and R. Gordon. 2005. Diagnostic error in internal medicine. Archives of Internal Medicine, 165:1493-1499.Slide63

References continued

Mamede

, S., et al. 2010. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. 304(11):1198-1203.

Meyer, A.N., et al. 2013. Physicians’ diagnostic accuracy, confidence, and resource requests. JAMA Internal Medicine, 173(21):1952-1959.

Miles, R.W. 2007. Fallacious reasoning and complexity as root causes of clinical inertia. Journal of the American Medical

Medical

Directors Association, 8:349-354.

Pennsylvania Patient Safety Advisory. 2010. Diagnostic error in acute care, 7(3):76-86.

Peterson, C., and M. Seligman. 2004. Humility and modesty, in Character Strengths and Virtues: A Handbook and Classification. New York: Oxford, pp. 461-475.

Redelmeier

, D.A., et al. 2001. Problems for clinical

judgement

: introducing cognitive psychology as one more basic science. Canadian Medical Association Journal, 164(3):358-360.

Rudolph, J.W., and J.B. Morrison. 2008. Sidestepping superstitious learning, ambiguity, and other roadblocks: a feedback model of diagnostic problem solving. American Journal of Medicine, 121(5A):S34-S37.

Sieck

, W.R., and H.

Arkes

. 2005. The recalcitrance of overconfidence and

aits

contribution to decision aid neglect. Journal of Behavioral Decision Making, 18:29-53.

Tangney, J.P. 2009. Humility, in S.J. Lopez and C.R. Snyder (eds.), The Oxford Handbook of Positive Psychology, 2

nd

ed. Available online.

Wikipedia. 2014. Overconfidence effect. Available at

http://en.wikipedia.org/wiki/Overconfidence_effect

.Slide64

“Overconfidence can be

beneficial to individual self-esteem

as well as giving an individual the will to succeed in their desired goal. Just believing in oneself may give one the

will to take one’s endeavors further than those who do not.” (Wikipedia, 2014)System 1 intuitive thinking may be associated with strong emotions such as

excitement and enthusiasm

. Such positive feelings, in turn, have been linked with an enhanced level of confidence in the decision maker’s own judgment” (

Croskerry

, 2008b)Slide65

Humility: from humus, “one’s condition of being flatly on the ground”

May

be a relatively rare human characteristic and antithetical to human nature

The self is remarkably resourceful at accentuating the positive and deflecting the negative“Self-enhancement biases” are pervasive (Tangney, 2009)