1. © 2006 Wotkyns Creative Dennis J. Boyle, MD Denver Health/UCDSOM COPIC 2014 Cognitive Error in Medicine Thinking like Sherlock

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

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

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

5. 5

6. 80,000 deaths a year Leape JAMA 2002 6

7. So what is a diagnostic error? 7

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

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

10. Cognitive error is different 10

11. Cognitive error is complex…  Evolving/NYD 11

12.  Evolving/NYD  Pt issues 12 Complex…

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

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

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

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 16

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

18. Can we afford to be perfect- breast imaging 18

19. And cognitive errors occur because…. 19

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

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

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

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

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

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

26. 26

27. Thin slicing - Separating wheat and chaff 27

28. Blink 28 Where is the lesion?

29. Blink 29

30. Blink 30 Where was the lesion?

31. System I - Blink 31

32. System II - Hypothetico-deductive style  Rigorous  List all possibilities  Probabilistic  Occurs in prefrontal cortex 32

33. System II- Hypothetico-deductive style Problem list  Lower GI symptoms  Arthralgias  High ESR  Low vitamin D  Low back pain  Osteoporosis J Hirsh 2011 Differential DX  Sprue  Reactive arthritis  Colitis w Spondy  Vasculitis-PAN  Fibromyalgia/ IBS w another cause of ESR 33

35. How much time do you spend in system I  20%  50%  75%  95% 35

36. How much time do you spend in system I  95% 36

37. The brain is a cognitive miser 37

38. Toggle function system I and II 38

39. Stress and fatigue push us to system I 39

40. The problem with System I is biases – name the bias 40

41. 41

42. 42 Anchoring bias - rely on first impression Premature closure – decide too early

43. 43 Last 2 patients had flu - Availability bias – what comes to mind

44. 44

45. Affection bias – taking care of loved ones Evolving - NYD 45

46. Framing bias – how it’s presented 46 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

47. Fast track patient with a cold 47

48. 48

49. Anchoring and framing biases 49

50. At sign out knee trauma F/U US 50

51. Framing and premature closure 51

52. Where is the lesion? 52 9

53. Search satisficing - Stop the diagnostic process once one diagnosis has been made- 53 9

54. December 2000

55. Ten Years Later

56. Alliteration bias – previous errors

57. 57 Anchoring bias is the big kahuna……

58. Top 10 fixes for diagnostic errors 58

59. #10 Reflective listening and build a story 59

60. #10 75% of the DX comes from the HX 60

61. #9 Mindfulness - reflective practice 61

62. #8 Build your knowledge base 62

63. #8 And try to figure it out 63

64. #7 Always do a differential Problem list  Lower GI symptoms  Arthralgias  High ESR  Low vitamin D  Low back pain  Osteoporosis J Hirsh 2011 Differential DX  Sprue  Reactive arthritis  Colitis w Spondy  Vasculitis-PAN  Fibromyalgia/ IBS w another cause of ESR 64

65. #6 Use your Bayes A 63 YO w CP and DM ? treadmill 65

66. #5 Use Occams razor 66

67. #4 IT –the original tricorder…think Amazon... 67

68. 68

69.  18 hour w/o sleep = ETOH 0.05%  And when you’re behind, tired or overloaded…. Beer pic #3- Be aware of stress

70. #2 – Always ask what else could this be? 70

71. #1 Think like Sherlock  Sherlock clip Manede Psych res 2010 71

72. So what do I do? If you’re sure What else could it be ? If You’re not - NYD 72

73. So what do I do? If you’re sure If You’re not - NYD S O A P Think like Sherlock! 73

74. Homework for all of us!!! If you’re sure What else could it be ? If You’re not - NYD S O A P Think like Sherlock! 74

75. 75 The problem is not knowledge but thinking. Can improve your diagnosing? Dennis Boyle M.D. dboyle@copic.com Please fill out the feedback form The rubber hits the road 1 ERS point