How to Think Straight- Cognitive Debiasing Pat Croskerry

How to think straight:How to think straight:Cognitive debiasingCognitive debiasing

Pat Croskerry MD, PhDPat Croskerry MD, PhD

SMACC Chicago June 23-26 2015SMACC Chicago June 23-26 2015

Who says we are not thinking straight?

Estimated number of preventable hospital deaths

due to diagnostic failure annually in the US

40,000 – 80,000

Leape, Berwick and Bates JAMA 2002

It is probably much higherIt is probably much higher

Diagnostic errors in the ICUDiagnostic errors in the ICUWinters et al, Winters et al, BMJ Q&S 2012BMJ Q&S 2012

• Review of 31 studies over 35 year period (1966-2011)• 5863 autopsies• 28% had at least one missed diagnosis• 8% caused or significantly contributed to death• 4 diagnoses accounted for 75% of all misses (MI, PE, Pneumonia, Aspergillosis)

• 40,000 ICU patients in the US die annually from misdiagnosis

Mostly, it’s not what we don’t know, Mostly, it’s not what we don’t know, it’s how we think.it’s how we think.

We need to know more about how We need to know more about how we think…we think…

Decision MakingDecision Making

Intuitive Intuitive (System 1)(System 1)

RationalRational (System 2)(System 2)

Fast Fast InformalInformal

SubjectiveSubjectiveContext-dependentContext-dependent

QualitativeQualitativeFlexibleFlexible

SlowSlow FormalFormal

ObjectiveObjectiveContext-independentContext-independent

QuantitativeQuantitativeRigourousRigourous

‘‘Cognitive thought is the tip of Cognitive thought is the tip of an enormous iceberg. It is the an enormous iceberg. It is the

rule of thumb among cognitive rule of thumb among cognitive scientists that unconscious scientists that unconscious

thought is 95% of all thought – thought is 95% of all thought – this 95% below the surface of this 95% below the surface of conscious awareness shapes conscious awareness shapes and structures all conscious and structures all conscious

thought’thought’ Lakoff and Johnson, 19Lakoff and Johnson, 199999

Medical Intuitions Medical Intuitions FastFast CompellingCompelling FrequentFrequent Minimal cognitive effort requiredMinimal cognitive effort required AddictiveAddictive Mostly serve us wellMostly serve us well Occasionally catastrophicOccasionally catastrophic

Analytic failures

Sound reasoning and problem solving may be based on incorrect assumptionsOverarching biases may influence the reasoning processIncomplete information

Seshia et al, JECP 2014

Major Organizations that Influence the Quality of

Evidence Informing

Healthcare

Diagnostic FailureDiagnostic Failure

15%

The ED is a difficult decision making The ED is a difficult decision making environmentenvironment

High decision densityDecision fatigue

Throughput pressuresWide range of illnessesDiagnostic uncertaintyNarrow time windows

Interruptions and distractionsShift work/Sleep disruption

Shift changes

Diagnostic error in the ED

Radiology: 5%Missed injuries: 12%Cardiovascular 19%

Respiratory: 30%

Overall ~16%

Pattern Recognition

Repetition

CognitiveDebiasing

Irrationaloverride Calibration SolutionPatient

ProblemPatternProcessor

RECOGNIZED

NOTRECOGNIZED

Intuition

Analytical

T

88 Main Features of the Model Main Features of the Model

• We spend most of our time in System 1We spend most of our time in System 1• Most heuristics and biases are in System 1Most heuristics and biases are in System 1• Most errors occur in System 1 Most errors occur in System 1 • Repetitive operations of System 2 >>> 1 Repetitive operations of System 2 >>> 1 • System 2 override of System 1System 2 override of System 1• System 1 override of System 2System 1 override of System 2• Toggle functionToggle function• Cognitive Miser function (being comfortably Cognitive Miser function (being comfortably

numb)numb)

When does the Cognitive Miser kick in?When does the Cognitive Miser kick in?

• All the time• Especially when the decision maker is

fatigued• Especially when sleep deprived• Especially when feeling down/depressed• Especially when resources are limited• During overcrowding/limited resources

So how do we become So how do we become better decision makers?better decision makers?

You aren’t thinking critically enough, so try harder

Is trying harder going to Is trying harder going to work?work?

The occasional smacc The occasional smacc might wake some people upmight wake some people up

What decision making needsWhat decision making needs

• Increased awareness of importance of decision makingIncreased awareness of importance of decision making• Know operating characteristics of DPT modelKnow operating characteristics of DPT model• Teach the main cognitive and affective biasesTeach the main cognitive and affective biases• Promote metacognition, mindfulness, reflectionPromote metacognition, mindfulness, reflection• Promote critical thinkingPromote critical thinking• Raise awareness of conditions which may compromise decision Raise awareness of conditions which may compromise decision

making (fatigue, sleep deprivation, cognitive overload)making (fatigue, sleep deprivation, cognitive overload)• Teach cognitive debiasingTeach cognitive debiasing

Cognitive DebiasingCognitive Debiasing

Major issuesMajor issues

Getting people to recognize there is a problem Accepting that change must occur Learning appropriate mindware

MindwarMindwaree

Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

Type11

Processes

Hard-WiredProcesses

Emotional Processes

Over-Learned Processes

ImplicitlyLearned Processes

We need to We need to maintain maintain

a feral vigilancea feral vigilance to detect biaseto detect biases

It ain’t It ain’t easyeasy

Even though bias detectedEven though bias detected Very unlikely one strategy works for allVery unlikely one strategy works for all Need for multiple approachesNeed for multiple approaches Very unlikely one shot will workVery unlikely one shot will work Need for multiple innoculationsNeed for multiple innoculations Need for extra vigilance in critical conditionsNeed for extra vigilance in critical conditions Need for lifelong maintenanceNeed for lifelong maintenance

The emerging cognitive debiasing The emerging cognitive debiasing literature in medicineliterature in medicine

No longer an option…