2. Critical thinking and its impact of patient safety Pat Croskerry MD, PhD Patient Safety Officer Course CPSI, Ottawa April 2011

3. Life is short, opportunities of knowing rare; our senses are fallacious, our reasonings uncertain; man therefore struggles with perpetual error from the cradle to the coffin.’ ‘Life is short, opportunities of knowing rare; our senses are fallacious, our reasonings uncertain; man therefore struggles with perpetual error from the cradle to the coffin.’ Erasmus Darwin, Zoonomia, 1794

4. This session is a focus on our most important faculty How we think

5. Seven Quick Questions Seven Quick Questions Take a piece of paper and write down your answers to each of these 7 questions You have about 10 seconds for each response

6. 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?

7. How many turtle doves did my true love send me on the 2 nd day of Christmas?

8. In 2010, the average time required to complete a root cause analysis was 15½ hours, how much time should be allowed for the three that are expected next month?

9. 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?

10. If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets?

11. 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?

12. In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study. Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs What is most likely? a. Jack is an engineer b. Jack is a lawyer De Neys & Glumicic, 2008

13. Answers A.30 B.2 C.46½ hours _________________________________ D. The ball costs 5¢ and the bat $1.05 E. 5 minutes F. 47 days F. 47 days G. Jack is a lawyer

14. In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study. Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs What is most likely? a. Jack is an engineer b. Jack is a lawyer De Neys & Glumicic, 2008

15. Cognitive Reflective Test The test distinguishes intuitive from analytical processingThe test distinguishes intuitive from analytical processing It tests the ability to resist first response that comes to mindIt tests the ability to resist first response that comes to mind Of 3428 people tested only 17% got all 3 correctOf 3428 people tested only 17% got all 3 correct 33% answered all three incorrectly33% answered all three incorrectly Frederick 2002 (MIT) Frederick 2002 (MIT)

16. The only decision we must make in our lives is how to live our lives L.J.Savage, 1954 ‘How to live our lives’ means ‘How to make decisions’ ‘How to make decisions’ Gigerenzer et al, 2002 Gigerenzer et al, 2002

17. What do we know about decision making?

19. A few examples More than half of marriages fail Chances of winning the lottery are 14,000,000:1 Most newspapers carry astrological forecasts All gambling systems are carefully designed to beat you, yet… Half the US population believes the universe is 6000 years old Most people think they are above average drivers We become addicted to many known harmful things Nations go to war to settle differences of opinion People universally believe their god is better than other gods 160 million have died in the last century over religious disputes 10 - 30% of children do not have the father they think they have 37% of US believe creationism should be taught instead of evolution Most university professors think their research area is more important Half the US population believes in UFOs 40% of Canadian Mensa believes in UFOs 9 million Americans reach the criterion for morbid obesity More than 6 out of 10 people believe in extra sensory perception

20. Extra-Sensory Perception?

21. James Randi Educational Foundation First offer of $1000 for proof of any psychic/paranormal event made in 1964 Now $1,000,000 (unclaimed) James Randi Educational Foundation 201 S.E. 12th Street Fort Lauderdale, FL 33316-1815 USA

22. How well do we make decisions?

23. A review of the (popular) literature

25. What factors adversely affect decision making? Biases Information gaps Ambient conditions Context Availability of resources Well-being of decision maker Cognitive loading Fatigue, sleep deprivation

26. Healthcare is not rocket science It’s a lot more complicated…

27. How might we think more critically?

28. Critical Thinking Knowledge of how we reason and make decisionsKnowledge of how we reason and make decisions To be able to recognize distracting stimuli, propaganda, irrelevanceTo be able to recognize distracting stimuli, propaganda, irrelevance To know and understand cognitive and affective biasTo know and understand cognitive and affective bias Ability to identify, analyze, and challenge assumptions in argumentsAbility to identify, analyze, and challenge assumptions in arguments Ability to recognize deception, deliberate or otherwiseAbility to recognize deception, deliberate or otherwise Capability to assess credibility of informationCapability to assess credibility of information Ability to monitor and control own thought processesAbility to monitor and control own thought processes Ability to imagine and explore alternativesAbility to imagine and explore alternatives Understanding of how to effectively work through problemsUnderstanding of how to effectively work through problems Capacity for making effective decisionsCapacity for making effective decisions

30. We have a new way of looking at decision making It can be applied to all decision making in healthcare

31. Type 1 and Type 2 processes (dual process theory)

32. Type 1 (intuitive) Cognitive style Heuristic Cognitive awareness Low Cost Low Automaticity High Rate Fast Reliability Low Errors Usually Effort Low Predictive power Low Emotional component High Scientific rigour Low Type 2 (analytical) Systematic High Low Slow High Few High Low High

33. Neuroanatomical correlates Type 1 processes:Type 1 processes: ventromedial prefrontal cortex, nucleus accumbens, amygdala, and lateral temporal cortex Type 2 processesType 2 processes : prefrontal cortex, hippocampus and medial temporal lobe, posterior parietal cortex

34. C1 C3 C2 X1X2 X3 X4 X4

35. Type 2 processing requires effort (22 to 34 Hz) PREFRONTAL CORTEX PARIETAL CORTEX Type 1 processing automatic and effortless (35 to 55 Hz) “Spatial” attention (25 to 45 Hz) Color identification (60 Hz) V4 MT

36. A schematic model for how the systems work together

38. Pattern Recognition Repetition Rational override Dysrationalia override CalibrationDiagnosis Patient Presentation Pattern Processor RECOGNIZED TYPE1 processes TYPE2 processes NOT RECOGNIZED

40. Pattern Recognition Repetition Executive override Dysrationalia override CalibrationDiagnosis Patient Presentation Pattern Processor RECOGNIZED NOT RECOGNIZED Type1 Processes Type2 Processes T

41. Calibra Decision Initial percept or problem Pattern Processor RECOGNIZED NOT RECOGNIZED System1 2 Novice Advanced Beginner Calibration Competence Proficiency Expertise

42. Toggle Function (Hypothesis Hopping)

43. Pattern Recognition Repetition Executive override Dysrationalia override CalibrationDiagnosis Patient Presentation Pattern Processor RECOGNIZED NOT RECOGNIZED Type1 Processes Type2 Processes T

44. 6 Main Features of the Model Toggle functionToggle function Most errors occur in System 1Most errors occur in System 1 Repetitive operations of System 2 >>> 1Repetitive operations of System 2 >>> 1 System 2 override of System 1System 2 override of System 1 System 1 override of System 2System 1 override of System 2 Cognitive Miser functionCognitive Miser function

45. BMJ Nov 2010

46. 2005

47. Blink Malcolm Gladwell (2005) ‘ We really only trust conscious decision making. But there are moments, particularly in times of stress, when haste does not make waste, when our snap judgments and first impressions can offer a much better means of making sense of the world. The first task of Blink is to convince you of a simple fact: decisions made very quickly can be every bit as good as decisions made cautiously and deliberately ‘ We really only trust conscious decision making. But there are moments, particularly in times of stress, when haste does not make waste, when our snap judgments and first impressions can offer a much better means of making sense of the world. The first task of Blink is to convince you of a simple fact: decisions made very quickly can be every bit as good as decisions made cautiously and deliberately’ P 14

48. 2006

49. Think Michael Legault (2006) ‘The technique by which we make good decisions and produce good work is a nuanced and interwoven mental process involving bits of emotion, observation, intuition, and critical reasoning. The emotion and intuition are the easy, “automatic” parts, the observation and critical reasoning skills the more difficult, acquired parts. The essential background to all this is a solid base of knowledge.’ P 12

50. The power of Type 1 processes

61. Swallowing saliva

62. Would you drink a glass of your own saliva?

63. The emotion of disgust (System 1) overcomes rational input (System 2)

66. How can we improve decision making in healthcare?

67. You aren’t thinking critically enough, so be more careful

68. The occasional slap might wake some people up

70. Other factors that may acutely compromise clinical decision making FatigueFatigue Illness, dysphoriaIllness, dysphoria Sleep deprivation, sleep debt, sleep inertiaSleep deprivation, sleep debt, sleep inertia Production pressures/RACQITOProduction pressures/RACQITO Group thinkGroup think

71. 10 things Dual Process Theory can do for us Provide a universal model for reasoning and decision making that embraces all approachesProvide a universal model for reasoning and decision making that embraces all approaches Provide a straightforward approach to teaching decision makingProvide a straightforward approach to teaching decision making Explain how experience/practice leads to ‘automatic’ behaviorExplain how experience/practice leads to ‘automatic’ behavior Explain how impulsive/irrational decision making occursExplain how impulsive/irrational decision making occurs Explain how impulsivity/irrational decisions can be overriddenExplain how impulsivity/irrational decisions can be overridden Show where cognitive and affective bias occursShow where cognitive and affective bias occurs Explain how fatigue and sleep deprivation cause decision failuresExplain how fatigue and sleep deprivation cause decision failures Predict cognitive miserly behaviorPredict cognitive miserly behavior Predict where weaknesses in the decision making process occurPredict where weaknesses in the decision making process occur Predict fruitful areas for researchPredict fruitful areas for research

72. How might we think more critically?

73. Critical Thinking Knowledge of how we reason and make decisionsKnowledge of how we reason and make decisions Able to recognize distracting stimuli, propaganda, irrelevanceAble to recognize distracting stimuli, propaganda, irrelevance Recognition of eccentric and sociocentric thinkingRecognition of eccentric and sociocentric thinking Intellectual humilityIntellectual humility To know and understand cognitive and affective biasTo know and understand cognitive and affective bias Able to identify, analyze, and challenge assumptions in argumentsAble to identify, analyze, and challenge assumptions in arguments Able to recognize deception, deliberate or otherwiseAble to recognize deception, deliberate or otherwise Capability to assess credibility of informationCapability to assess credibility of information Ability to monitor and control own thought processesAbility to monitor and control own thought processes Ability to imagine and explore alternativesAbility to imagine and explore alternatives Understanding of how to effectively work through problemsUnderstanding of how to effectively work through problems Capacity for making effective decisionsCapacity for making effective decisions

74. ‘Cognitive thought is the tip of an enormous iceberg. It is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought – this 95% below the surface of conscious awareness shapes and structures all conscious thought’ Lakoff and Johnson, 1999

75. Robin Hogarth

76. Educating Intuition Select/create decision–making environment Improve feedback Impose circuit breakers Acknowledge emotions Explore connections Accept conflict in choice Make scientific method intuitive