Clinical Decision Making + Strategies for Cognitive Debiasing Pat Croskerry MD, PhD, FRCP(Edin) International Association of Endodontists Scottsdale, Arizona June 2019 Financial Disclosures or other Conflicts of Interest None It is estimated that an American adult makes 35,000 decisions a day i.e. about 2200 each waking hour Sollisch J: The cure for decision fatigue. Wall Street Journal, 2016 Decision making ‘The most important decision we need to make in Life is how we are going to make decisions’ Professor Gigerenzer Is there a problem with the way we think and make decisions? 3 domains of decision making Patients Healthcare leadership Healthcare providers Patients Leading Medical Causes of Death in the US and their Preventability in 2000 Cause Total Preventability (%) Heart disease 710,760 46 Malignant neoplasms 553,091 66 Cerebrovascular 167,661 43 Chronic respiratory 122,009 76 Accidents 97,900 44 Diabetes mellitus 69,301 33 Acute respiratory 65,313 23 Suicide 29,350 100 Chronic Liver disease 26,552 75 Hypertension/renal 12,228 68 Assault (homicide) 16,765 100 All other 391,904 14 Keeney (2008) Healthcare leadership Campbell et al, 2017 Healthcare providers US deaths in 2013 • 611,105 Heart disease • 584,881 Cancer • 251,454 Medical error Medical error is the 3rd leading cause of death Estimated number of preventable hospital deaths due to diagnostic failure annually in the US 40,000 – 80,000 Leape, Berwick and Bates JAMA 2002 Diagnostic failure is the biggest problem in patient safety Newman-Toker, 2017 Sources of Diagnostic Failure The System 25% The Individual 75% Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what’s the goal? Acad Med. 2002 What is the individual’s problem? Isn’t bright enough Doesn’t know enough Isn’t trying hard enough Isn’t thinking rationally Is not having a good day Structure of knowledge in endodontics following Bloom’s taxonomy (Adapted from Mack et al, Asia Pacific J Ophthal, 2018) Level Type of Description Examples Endodontics-specific knowledge example A Factual Basic elements that must Technical Anatomy of dentition knowledge be known to solve vocabulary problems B Concept Interrelationships among Theory of Pathophysiology of pulp knowledge these elements that evolution disease enable them to function together C Procedural Methods of enquiry and Scientific method Operating skills knowledge criteria for using subject- specific skills D Metacognitive Knowledge of cognition Awareness of Knowledge of the use knowledge and awareness and one’s own of heuristics and their knowledge of one’s own metacognitive associated biases cognition ability Diagnostic Failure 15% It varies by specialty Dermatology Radiology (1-2%) Anatomic pathology Internal medicine Family medicine (~15%+) Emergency medicine Endodontics ? Legal outcome by critical incident CMPA Data : 347 legal actions closed 2005 - 2009 240 Number of 200 patients 160 120 80 40 0 Perform Comm Diagnosis Admin Medication Conduct Legal outcome by critical incident CMPA Data : 347 legal actions closed 2005 - 2009 240 200 160 120 80 40 0 Perform Comm Diagnosis Admin Medication Conduct Legal outcome by critical incident CMPA Data : 347 legal actions closed 2005 - 2009 240 200 160 120 80 40 0 Perform Comm Diagnosis Admin Medication Conduct So how good is our decision making? Eight Quick Questions Take a piece of paper and write down your answers to each of these 8 questions You have about 10 seconds for each response On a standard Ottawa fire truck, there are 2 drivers up front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks? A. 25 B. 35 C. 30 A. the ball follows a parabola travelling forward as it falls B. the ball drops straight downwards from the point of release C. The ball moves backwards and downwards A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost? A. 5¢ B. 15¢ C. 10¢ If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets? A. 5 minutes B. 100 minutes C. 50 minutes In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake? A.28 days B. 24 days C. 47 days The graph shows changes in variable A (black line) and variable B (red line) from 2000 - 2009 How would you describe the relationship between A and B? (a) Closely related (b) Independent of each other (c) Cannot say Year A B A: The ball continues in a straight line when the string breaks B: The ball follows a curved path when the string breaks C. The ball follows some other trajectory when the string breaks A 50 year old woman, with no symptoms, takes part in routine mammographic screening, and tests positive. She is very worried and wants to know what her chances are of having breast cancer. You know nothing else about her. The test has a specificity of 90%, and a false positive rate of 9% A. 9 in 10 B. 1 in 100 C. 1 in 10 Answers 1. (C) 30 firemen 2. (A) The ball follows a parabola forwards 3. The ball costs 5 cents 4. (A) Five minutes 5. (C) 47 days 6. Cannot say if A is related to B. 7. (A). The ball continues in a straight line 8. (D) 1 in 10 Cognitive Reflective Test (questions 3, 4, 5) • The test distinguishes intuitive from analytical processing • It tests your ability to resist first response that comes to mind • Of 3428 people tested only 17% got all 3 correct • 33% answered all three incorrectly Frederick 2002 (MIT) So how much can we trust our intuitions? Intuitions in Healthcare . Fast . Compelling . Frequent . Minimal cognitive effort required . Addictive . Mostly serve us well . Occasionally catastrophic (not rational) How does rationality fail? 3 basic problems with decision making • hasty judgments • distorted probability estimates • biased judgments Mindware Rationality Failure Processing problems Content problems Cognitive Mindware Mindware miserliness gaps contamination Minimising cognitive effort Knowledge deficits Cognitive biases Accepting things at face value Impaired numeracy Affective biases Intemperate heuristic use Impaired scientific thinking Endorsement of implausible beliefs Superficiality Impaired probability thinking Cultural conditioning Insufficient breadth and depth Illogical reasoning Indoctrination Close-mindedness Lack of awareness of bias WYSIATI Incomplete critical thinking tools (Hasty judgments) (Distorted probability estimates) (Biased judgments) ‘Everything from investment fiascos to medical error has been linked to ‘contaminated mindware’. Facing up to it is the first step towards better decisions’ Stanovich, Toplak and West, 2010 What does rationality look like? Deliberate Objective reasoning style Knowledgeable Evidence based Minimal bias Careful, considered Thoughtful, Not impulsive Reflective Mindful Mostly, it’s not what we don’t know, it’s how we think We need to know more about how we think… 2005 2006 How then do we think, reason and make decisions? Clinical decision making Rational Intuitive Slow Fast Deliberate Autonomous Objective Context dependent Scientific Qualitative Few errors Error prone The Capacity to Reflect • Less impulsivity in decision making • Metacognition • De-coupling from the intuitive mode • Increased likelihood of bias detection • Increased likelihood of de-biased decisions • Hallmark of a critical thinker Dual Process Theory 2011 Dual Process Decision Making Dual Process Decision Making System 1: System 2: Automatic/streamlined Cautious/complex Healthcare decision making Racing bike Mountain bike Slow Fast Deliberate Autonomous Objective Context dependent Scientific Qualitative Few errors Error prone Type 1 and Type 2 processes (dual process theory) Hope he’s not just trusting his intuition on this one X4 C C 2 3 X3 C X2 X1 1 X4 Intuition RECOGNIZED Pattern Pattern Executive Dysrationalia Patient Recognition T Calibration Solution Problem Processor override override Repetition NOT Analytical RECOGNIZED “Getting” medicine is not easy Life is about learning the basic patterns COW “Getting” medicine is not easy “Getting” medicine is not easy “Getting” medicine is not easy Intuition RECOGNIZED Pattern Pattern Executive Dysrationalia Patient Recognition T Calibration Solution Problem Processor override override Repetition NOT Analytical RECOGNIZED System RECOGNIZED 1 Expertise Proficiency Initial percept Pattern Competence Calibration Decision or Processor Calibra problem Advanced Beginner Novice System NOT RECOGNIZED 2 Axial view of fMRI activation of the brain as a function of practice over 60 minutes Hill and Schneider, 2006 B C Type Type RECOGNIZED 1 1 Process Process Adaptive Critical thinking Expertise Metacognitive processes Mindware Rationality, biases Routine Routine Gap Lateral thinking Expertise Expertise Humanities Proficiency Proficiency Clinical Pattern problem Processor Competenc Competenc features e e Advanced Advanced Beginner Beginner Novice Novice Type Type NOT 2 2 RECOGNIZED Process Processes Unconsciously Consciously Consciously Unconsciously Adaptive incompetent incompetent competent competent expertise 40 Hours 10,000 Hours Toggle Function (Hypothesis Hopping) 8 Main Features of the Model • We spend most of our time in System 1 • Most heuristics and biases are in System 1 • Most errors occur in System 1 • Repetitive operations of System 2 >>> 1 • System 2 override of System 1 • System 1 override of System 2 • Toggle function • Cognitive Miser function