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Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014

Cognitive Error in Medicine Thinking like Sherlock. Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014. Scope of the problem How we diagnose Examples Improving the process. 1. 2. 5. 3. 4. Outline.

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Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014

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  1. Cognitive Error in MedicineThinking like Sherlock Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014

  2. Scope of the problem How we diagnose Examples Improving the process 1 2 5 3 4 Outline

  3. The diagnosis is every doctor's measure of his own abilities and is the most important ingredient of his self-image Nuland 1994

  4. The death of one man is a tragedy The death of millions is a statistic Stalin

  5. The death of one man is a tragedy The death of millions is a statistic Stalin

  6. 80,000 deaths a year Leape JAMA 2002

  7. So what is a diagnostic error?

  8. What is a diagnostic error? A missed or delayed opportunity to make a timely diagnosis Singh JAMA IM 2013

  9. Diagnostic error is divided into cognitive and systems. Today we will look at cognitive…

  10. Cognitive error is different

  11. Cognitive error is complex… • Evolving/NYD

  12. Complex… • Evolving/NYD • Pt issues

  13. Complex… • Evolving/NYD • Pt issues • System issues

  14. Complex… • Evolving/NYD • Pt issues • System issues

  15. Complex… • Evolving/NYD • Pt issues • System issues • WHO 12,420 diseases

  16. Error rate • 80% of charts no diff DX • 54% feel they make one error/month • Rad/Path rate 2% • IM rate 10 – 15% • 1/1000 outpatient visits Singh 2013 Graber Am Jmed 2008 Arthur Elstein

  17. Error results in…… • #1 cause of lawsuits • Overtreatment • Emotional impact • Wasted money and time Gelhart NEJM 2009

  18. Can we afford to be perfect- breast imaging

  19. And cognitive errors occur because….

  20. But it’s still complicated…..A stroke alert story

  21. But it’s still complicated…..A stroke alert story

  22. Kahneman and Tvertsky How we think - System I vs. System II

  23. Kahneman and Tvertsky How we think - System I vs. System II

  24. Kahneman and Tvertsky How we think - System I vs. System II

  25. Lehrer J How we decide. 2009 Where does this all happen?

  26. Thin slicing - Separating wheat and chaff

  27. Blink Where is the lesion?

  28. Blink

  29. Blink Where was the lesion?

  30. System I - Blink

  31. System II - Hypothetico-deductive style • Rigorous • List all possibilities • Probabilistic • Occurs in prefrontal cortex

  32. System II- Hypothetico-deductive style Problem list Differential DX Sprue Reactive arthritis Colitis w Spondy Vasculitis-PAN Fibromyalgia/ IBS w another cause of ESR • Lower GI symptoms • Arthralgias • High ESR • Low vitamin D • Low back pain • Osteoporosis J Hirsh 2011

  33. How much time do you spend in system I • 20% • 50% • 75% • 95%

  34. How much time do you spend in system I • 95%

  35. The brain is a cognitive miser

  36. Toggle function system I and II

  37. Stress and fatigue push us to system I

  38. The problem with System I is biases – name the bias

  39. Anchoring bias - rely on first impressionPremature closure – decide too early

  40. Last 2 patients had flu - Availability bias – what comes to mind

  41. Affection bias –taking care of loved ones Evolving - NYD

  42. Framing bias – how it’s presented I’ve got this pt I’d like you to see. She’s a psych patient with CP….. He’s a drunk with abdominal pain Mcneil NEJM 1982

  43. Fast track patient with a cold

  44. Anchoring and framing biases

  45. At sign out knee trauma F/U US

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