Teaching Internal Medicine Residents About Cognitive Bias a PowerPoint Presentation

Teaching Internal Medicine Residents About Cognitive Bias a PowerPoint Presentation

2015-10-27 156K 156 0 0

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James B. Reilly MD, MS, FACP. Diagnostic Errors in Medicine. Objectives. Describe a longitudinal curriculum for internal medicine residents in cognitive bias and diagnostic error. Present our educational outcomes. ID: 173355

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Slide1

Teaching Internal Medicine Residents About Cognitive Bias and Diagnostic Error

James B. Reilly MD, MS, FACPDiagnostic Errors in Medicine

Slide2

Objectives

Describe a longitudinal curriculum for internal medicine residents in cognitive bias and diagnostic error

Present our educational outcomes

Discuss strengths, limitations and lessons learned from our experience

Propose next steps for future educational innovation and research

Slide3

Background

Patient Safety Education in Graduate Medical Education is systems-focused

Teaching about Cognitive Bias as a contributor to diagnostic error is a nascent field

Previous educational studies have been:

Single session

Medical Students >>> Residents

Grounded in hypothetical cases

Slower to utilize multimedia approaches

Slide4

40 Minute Didactic20 Minute Facilitated Case-Based Discussion (RCA)

10 Minute Review50 Minute Narrative Reflection & Group Discussion

Web Curriculum:Diagnostic RCACase: Bias Recognition

June 2010

Oct 2010

May – Sep 2011

Longitudinal Curriculum in

Cognitive Bias and Diagnostic Errors

SESSION 1

SESSION 2

SESSION 3

Slide5

40 Minute Didactic20 Minute Facilitated Case-Based Discussion (RCA)

10 Minute Review50 Minute Narrative Reflection & Group Discussion

Web Curriculum:Diagnostic RCACase: Bias Recognition

June 2010

Oct 2010

May – Sep 2011

Longitudinal Curriculum in

Cognitive Bias and Diagnostic Errors

SESSION 1

SESSION 2

SESSION 3

SESSION 1 OBJECTIVES

Appreciate the impact of diagnostic errors in medicine

Differentiate systems errors from cognitive errors

Identify common biases

Slide6

40 Minute Didactic20 Minute Facilitated Case-Based Discussion (RCA)

10 Minute Review50 Minute Narrative Reflection & Group Discussion

Web Curriculum:Diagnostic RCACase: Bias Recognition

June 2010

Oct 2010

May – Sep 2011

Longitudinal Curriculum in

Cognitive Bias and Diagnostic Errors

SESSION 1

SESSION 2

SESSION 3

SESSION 2 OBJECTIVES

Reflect upon a case in which MD cognitive bias impacted patient

Discuss why the error may have occurred and future prevention strategies

Slide7

40 Minute Didactic20 Minute Facilitated Case-Based Discussion (RCA)

10 Minute Review50 Minute Narrative Reflection & Group Discussion

Web Curriculum:Diagnostic RCACase: Bias Recognition

June 2010

Oct 2010

May– Sep 2011

Longitudinal Curriculum in

Cognitive Bias and Diagnostic Errors

SESSION 1

SESSION 2

SESSION 3

SESSION 3 OBJECTIVES

Identify and differentiate systems from cognitive errors with

diagnostic error fishbone diagram

Recognize cognitive bias in videotaped, simulated clinical scenarios

Slide8

“Diagnostic Error Fishbone”

Example Factors:

A =The diagnosis of CHF “stuck” after the Emergency Room used it in their clinical presentation to the medicine housestaff

B =There was a delay in obtaining the home medication list

Slide9

Slide10

Results

Thirty-eight PGY-2 Residents completed all 3 sessions

Knowledge Assessment:

Post-curriculum mean 9.26 vs. 8.26 pre-curriculum

p = 0.006

Contemporary 3

rd

year controls scored 7.69

p < 0.001

Bias Identification and Suggestion of De-biasing strategies in response to video cases

100% identified at least one bias seen in the video

95% identified two, and 65% identified three or more

100% suggested at least one appropriate de-bias strategy

97% suggested two, and 61% suggested three or more

Slide11

Question 8:

A 58 year old female with diabetes presents to the ED in with SOB upper respiratory symptoms. The triage nurse takes the patient’s vital signs and places her in a room, informing the doctor of “another patient with the flu.” The patient reports that she has been drinking plenty of fluids and taking aspirin, to treat her symptoms. On exam, she is not hypoxic, her lungs are clear, but she is noted to be

tachypneic

(RR 30). Labs are normal with only slightly decreased bicarbonate of 18. She is admitted to medicine for supportive care for presumed viral pneumonia. Further work up revealed aspirin toxicity. Which of the following is the most likely reason for the missed diagnosis?

a. Serum HCO3 levels in the ED are often inaccurate and the physician assumed this was an inaccurate reading.

b. The physician’s lack of knowledge of the presenting symptoms of

salicylate

toxicity

c. The physician relied on his experiences with seasonal patterns of illness to make diagnoses of common syndromes

d. The syndromes of

salicylate

toxicity and viral pneumonia are often so similar as to make occasional misdiagnosis inevitable.

Slide12

Cognitive Biases Recognized by Residents

Cognitive Bias%Anchoring87.8%Availability75.6%Framing Effect56.1%Blind Obedience53.7%Unpacking53.7%Confirmation48.8%Diag. Momentum48.8%Visceral bias48.8%

Ogdie AR, Reilly JB, et al. Acad Med 2012

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Anchoring

“Once she came in, we had an impression of her…it was this giant bias in the room…if he’s got this huge lung cancer, chest pain in a cancer patient with a lung primary is probably going to be cancer pain.”

Slide14

Blind Obedience

“I think I fell into that bias initially in that I deferred to authority probably for too long and I should’ve been more aggressive in pushing for what I felt the patient needed to have done…”

Slide15

Specialty Service

Anchoring

Availability

Framing Effect

Blind Obediance

Lack of Confidence

Consultants Integral

Hierarchy

Too busy

Too many patients

Vague History

Night Float

Handoff

Chronic Illness

Diagnostic Momentum

Unpacking Principle

Confirmation Bias

Visceral Bias

Provider Fatigue

Provider Disinterest

Transfer

Ogdie AR, Reilly JB, et al. Acad Med 2012

The Importance of Context

Slide16

Challenges

Knowledge assessmentFaculty DevelopmentGetting Time in a busy residency curriculumTechnical Aspects of Web Curriculum

Slide17

Lessons Learned: Tips for GME…

Think Big, Start SmallBe OpportunisticAnticipate resistance from the learners (and faculty!)Appreciate the importance of context on thinkingEngage other faculty

Slide18

Next Steps

Refine and validate assessment toolDisseminate Web ModuleDevise/test educational strategies that can be incorporated into the clinical environmentCollaborate

Slide19

Acknowledgements

Jen Myers, MDAlexis Ogdie, MDJoan von Feldt, MD MEd.Lisa Bellini, MD Penn IM ResidentsAmanda Lerman, MD“Dr. Quick”Lauren Weinberger, MD “ED Attending”Jen Kogan, MD“Dr. Rush”

Our Faculty Group LeadersMatt RuskTodd BartonKaren WarburtonJeff GreenblattDave AizenbergSteve KimJodi LenkoSteve Gluckman


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