Recognizing Clinical Reasoning Errors

Heidi Chumley, MD Associate Professor, Family Medicine

Session Objectives

• At the end of this session, participants should be able to: – Outline the steps of the clinical reasoning process.

– Define cognitive dispositions to respond (CDRs) and describe several CDRs seen with diagnostic reasoning errors. – Recognize clinical reasoning errors in common educational settings.

Clinical Reasoning

• “the cognitive process necessary to evaluate and manage a medical problem” Reasoning Skill Knowledge

Medical Errors

• 44,000 to 98,000 deaths per year due to medical errors • Many systematic and individual factors contribute to medical errors • Recent attention on cognitive errors (clinical reasoning, diagnostic reasoning, decision-making)

Cognitive Errors

Zhang, JAMIA, 2002

Cognitive Errors

• Of 301 Malpractice claims, 59% involved diagnostic errors that led to poor outcomes – Gandhi, 2006 • Of patients admitted with 10 days of outpatient visit, 10% due to diagnostic error – Singh, 2007 • Autopsy series showed 24% missed diagnosis – Shojania, 2003

Diagnostic process

Differential Diagnosis Generation Information gathering Diagnosis Refinement Diagnosis Verification

Why are errors made?

• Failure/delay of eliciting information – Singh, 2007 • Suboptimal weighing of critical pieces of information from H&P – Singh, 2007 • Overreliance on diagnostic testing – Bordage, 1999

Cognitive Dispositions to Respond

• Biases that can lead to diagnostic errors • Mental shortcuts running amuck • Croskerry defines 32, Acad Med, 2003: 78(8)

Cognitive Dispositions to Respond

• Information-gathering – Unpacking – Availability – Anchoring – Premature closure • System – Diagnosis momentum – Feedback sanction – Triage cueing • Probability – Aggregate bias – Base-rate neglect – Gender bias – Gambler’s fallacy – Posterior probability error Croskerry, 2003

Information-gathering problems

• Unpacking – failure to elicit all relevant information • Availability – recent exposure influences diagnosis • Anchoring – holding onto a diagnosis after receiving contradictory information • Premature closure – accepting a diagnosis before it is fully verified Present at all levels, start watching for these in students

Clues to Information-Gathering Problems • Limited differential diagnosis (unpacking, availability) • Lack of attention to contradictory information (anchoring) • Lack of pertinent negatives (premature closure)

Diagnostic Errors

Differential Diagnosis Generation Unpacking Availability Anchoring Information gathering Diagnosis Refinement Premature closure Diagnosis Verification

Systems contributions

• Diagnosis momentum – early diagnosis by another provider is accepted as definite • Feedback sanction – final diagnosis does not return to initial decision-maker • Triage cueing – location cues management (seen through the lens of the first provider) Present at all levels, more likely to see in residents

Clues to System Contributors

• Lack of primary symptom data (diagnostic momentum) • Inattention to closing the loop (feedback sanction) • Non diagnoses: non-cardiac chest pain; no gynecologic cause for lower abdominal pain (triage cueing)

Probability Pitfalls

• Aggregate bias – aggregate data do not apply to my patients • Base-rate neglect – ignoring the true prevalence • Gender bias – gender inappropriately colors probability • Gambler’s fallacy – sequence of same diagnoses will not continue • Posterior probability – sequence of same diagnoses will continue Best seen during continuity experiences, residency

Clues to Probability Pitfalls

• Didn’t meet criteria, but I…(aggregate) • Rare diagnoses high on list, increased testing (base-rate neglect) • Comments about probability (Gambler’s fallacy, posterior probability)

Two Others

• Representative restraint – ruled out because the presentation is not typical • Search satisfying – search is called off when something is found

Summing Up

• Reasoning errors are common • Identifying/naming the CDRs is an important part of reflection • No gold standard for assessing reasoning in our learners – nothing to replace our conversations and helping them think about how they are thinking • Are cognitive errors treatable? Yes

Questions?