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Cognitive Bias Mitigation: Becoming Better Diagnosticians

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Cognitive Bias Mitigation: Becoming Better Diagnosticians 15 Cognitive Bias Mitigation: Becoming Better Diagnosticians Pat Croskerry CONTENTS Introduction .........................................................................................................258 Pervasiveness of Bias ..........................................................................................259 Cognitive Bias Mitigation ..................................................................................260 Principle Strategies for Cognitive Debiasing .................................................. 261 Getting Clinicians past the Precontemplative Stage ................................. 261 Dual Process Theory Training (DPTT) ........................................................ 262 Bias Inoculation (BI) ....................................................................................... 262 Specific Educational Interventions (SEI) .....................................................264 Interactive Serious Computer Games (ISCG) ............................................264 Cognitive Tutoring Systems (CTS) ...............................................................264 Get More Information (I) ...............................................................................264 Structured Data Acquisition (SDA) .............................................................265 Being More Skeptical (S) ...............................................................................265 Affective Debiasing (AD) ..............................................................................265 Forcing Functions (FF) ...................................................................................266 Metacognition, Mindfulness, and Reflection (MMR) ...............................268 Slowing Down (SD) Strategies .....................................................................268 Re-Biasing (RB) ............................................................................................... 269 Group Decision Strategy (GDS) ................................................................... 269 Public Policy Decision Making ..................................................................... 269 Personal Accountability (PA) ........................................................................ 269 Educating Intuition ........................................................................................ 270 257 9781409432333_C015.indd 257 2/3/17 1:12 PM 258 Diagnosis: Interpreting the Shadows Sparklines ........................................................................................................ 270 Cultural Training ............................................................................................ 270 Are All Biases Created Equal? ........................................................................... 270 Prescriptive Decision Making ...........................................................................272 Are There Specific Cognitive Pills for Cognitive Ills? ...............................272 Are There Specific Situations in Which Biases Are More Frequent? ...... 273 How Does CBM Actually Work? ...................................................................... 273 Conclusions .......................................................................................................... 281 References ............................................................................................................283 Introduction Many human behaviors are extremely resistant to change. Virtually all behavior is preceded by cognition on some level; therefore, any discussion about behavioral change is really about changing cognition. Considerable challenges are experienced in a wide variety of domains; therapists working in the field of addiction behaviors face formidable difficulties in undoing acquired, harmful behaviors; the judicial system constantly seeks to change behaviors unacceptable to society; doctors face the ongoing task of motivating their patients to change unhealthy behaviors; coaches need to continuously refine and shape the behavior of their athletes; teachers need to instill new behaviors in their learners but also extinguish old ones; knowledge uptake and implementation in many fields, especially science, is a major challenge, and throughout there are abundant biases in human decision making that continuously undermine rationality. Secular and nonsecular thoughts and belief systems are often characterized by severely biased thinking and an ideological extremism that has accounted for human suffering on an extraor- dinary scale. Creating unbiased, balanced, rational thinkers is perhaps the greatest challenge that societies face. For us all, it is a lifelong journey for which cognitive debiasing is a vital and necessary tool. Given that cognitive factors appear to underlie the majority of diagnostic failures, cognitive debi- asing strategies for clinical reasoning are a critically important issue. Broadly speaking, clinical decisions about patient diagnoses are made in one of two modes: either rational or intuitive . The former is fairly reliable, safe, and effective, but slow and resource-intensive (Chapters 3 and 7). The latter is faster, more commonly used, and usually effective, but more com- monly associated with failure. The intuitive mode of decision making is characterized by heuristics, such as short-cuts, abbreviated ways of think- ing, and maxims like “ I’ ve seen this many times before” . It is a rule of thumb among cognitive psychologists that we spend about 95% of our time in the intuitive mode [1]. We perform many of our daily activities through serial associations— one thing automatically triggering the next, with few epi- sodes of conscious, deliberate, focused, analytical thinking. Thus, we have a prevailing disposition to use heuristics, and while they work well most 9781409432333_C015.indd 258 2/3/17 1:12 PM Cognitive Bias Mitigation: Becoming Better Diagnosticians 259 of the time, they are intrinsically vulnerable to error. Our systematic errors are termed biases [2], of which there are many, including over one hundred cognitive biases [3] and probably about a dozen or so affective biases (ways in which our feelings influence our judgment) [4]. Pervasiveness of Bias Bias is inherent in human judgment and decision making [5]. It is the prin- cipal factor underlying erroneous decision making (Chapter 8: The Rational Diagnostician). Its importance has been recognized beyond the individual at an organizational level in healthcare (Figure 15.1) [6,7] and by the broader scientific community [8]. Seshia et al. [6] use the term cognitive biases plus to describe the collective influence of cognitive biases, logical fallacies, conflicts Healthcare related Patient industry Political advocacy influences groups Publication Healthcare industry regulators Healthcare Healthcare Non- professionals industry and societies funders Hospitals, health Researchers authorities Universities FIGURE 15.1 Ten major organizations in healthcare that are vulnerable to the influence of cognitive biases, fallacies, conflicts of interest, and ethical violations. (Reprinted with permission from Seshia, S.S. et al., J Eval Clin Pract ., 20(6), 735, 2014.) 9781409432333_C015.indd 259 2/3/17 1:12 PM 260 Diagnosis: Interpreting the Shadows of interest, and ethical violations on individuals and organizations in health- care. All four of them lead to distorted reasoning and decision making. Biases have been described as “ predictable deviations from rationality” [9]. Many biases that diagnosticians hold are often recognized and corrected by themselves. Essentially, this is the process that underlies learning and the refinement of clinical behavior. We may learn an inappropriate response to a particular situation that leads to a maladaptive habit, but then some insight or revelation occurs and we change our ways to achieve a more successful outcome. However, the persistence of particular biases that appear resistant to change has attracted the interest of research studies and is the focus of cognitive debiasing [10– 15], perhaps more accurately known as cognitive bias mitigation (CBM) as it is more likely that we can reduce as opposed to eliminate bias. The basic argument is that if we can effectively reduce bias in our thinking, we will become better thinkers and improve our clinical reasoning skills. Besides the general vulnerability of the human mind towards biases in decision making, there is clear evidence that the quality of decision mak- ing is also influenced by ambient factors, or prevailing conditions in the immediate environment in which decisions are being made, including context, team factors, patient factors, resource limitations, physical plant design, ergonomic factors (Chapters 11 and 17) and individual homeostatic factors such as affective state, general fatigue, cognitive loading, decision fatigue, interruptions and distractions, sleep deprivation, and sleep-debt (Chapter 9). Thus, the tendency towards biased decisions may be exacer- bated by ambient conditions. Individual factors such as personality, intel- ligence, rationality, gender, and other variables are also known to impact decision making (Chapter 9). Psychopathology, nonsecular beliefs, post- modernism, deconstructuralism, and magical thinking are generally not considered in these discussions, although all clearly have the potential to exert powerful influences on rationality. Cognitive Bias Mitigation There are two questions: Firstly, can we improve our decisions by CBM? This means appropriately
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