Geeta Singhal

Cognitive debiasing 1: origins of bias and theory of debiasing

Numerous studies have shown that diagnostic failure depends upon a variety of factors. Psychological factors are fundamental in influencing the cognitive performance of the decision maker. In this first of two papers, we discuss the basics of reasoning and the Dual Process Theory (DPT) of decision making. The general properties of the DPT model, as it applies to diagnostic reasoning, are reviewed. A variety of cognitive and affective biases are known to compromise the decision-making process. They mostly appear to originate in the fast intuitive processes of Type 1 that dominate (or drive) decision making. Type 1 processes work well most of the time but they may open the door for biases. Removing or at least mitigating these biases would appear to be an important goal. We will also review the origins of biases. The consensus is that there are two major sources: innate, hard-wired biases that developed in our evolutionary past, and acquired biases established in the course of development and within our working environments. Both are associated with abbreviated decision making in the form of heuristics. Other work suggests that ambient and contextual factors may create high risk situations that dispose decision makers to particular biases. Fatigue, sleep deprivation and cognitive overload appear to be important determinants. The theoretical basis of several approaches towards debiasing is then discussed. All share a common feature that involves a deliberate decoupling from Type 1 intuitive processing and moving to Type 2 analytical processing so that eventually unexamined intuitive judgments can be submitted to verification. This decoupling step appears to be the critical feature of cognitive and affective debiasing.

Cognitive debiasing 2: impediments to and strategies for change

In a companion paper, we proposed that cognitive debiasing is a skill essential in developing sound clinical reasoning to mitigate the incidence of diagnostic failure. We reviewed the origins of cognitive biases and some proposed mechanisms for how debiasing processes might work. In this paper, we first outline a general schema of how cognitive change occurs and the constraints that may apply. We review a variety of individual factors, many of them biases themselves, which may be impediments to change. We then examine the major strategies that have been developed in the social sciences and in medicine to achieve cognitive and affective debiasing, including the important concept of forcing functions. The abundance and rich variety of approaches that exist in the literature and in individual clinical domains illustrate the difficulties inherent in achieving cognitive change, and also the need for such interventions. Ongoing cognitive debiasing is arguably the most important feature of the critical thinker and the well-calibrated mind. We outline three groups of suggested interventions going forward: educational strategies, workplace strategies and forcing functions. We stress the importance of ambient and contextual influences on the quality of individual decision making and the need to address factors known to impair calibration of the decision maker. We also emphasise the importance of introducing these concepts and corollary development of training in critical thinking in the undergraduate level in medical education.

Errors of Diagnosis in Pediatric Practice: A Multisite Survey

OBJECTIVE: We surveyed pediatricians to elicit their perceptions regarding frequency, contributing factors, and potential system- and provider-based solutions to address diagnostic errors. METHODS: Academic, community, and trainee pediatricians (N = 1362) at 3 tertiary care institutions and 109 affiliated clinics were invited to complete the survey anonymously through an Internet survey administration service between November 2008 and May 2009. RESULTS: The overall response rate was 53% (N = 726). More than one-half (54%) of respondents reported that they made a diagnostic error at least once or twice per month; this frequency was markedly higher (77%) among trainees. Almost one-half (45%) of respondents reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination, or chart review was the most-commonly reported process breakdown, whereas inadequate care coordination and teamwork was the most-commonly reported system factor. Viral illnesses being diagnosed as bacterial illnesses was the most-commonly reported diagnostic error, followed by misdiagnosis of medication side effects, psychiatric disorders, and appendicitis. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors. CONCLUSION: Pediatricians reported making diagnostic errors relatively frequently, and patient harm from these errors was not uncommon.

Preparing for the Changing Role of Instructional Technologies in Medical Education

As part of an international faculty development conference in February 2010, a working group of medical educators and physicians discussed the changing role of instructional technologies and made recommendations for supporting faculty in using these technologies in medical education. The resulting discussion highlighted ways technology is transforming the entire process of medical education and identified several converging trends that have implications for how medical educators might prepare for the next decade. These trends include the explosion of new information; all information, including both health knowledge and medical records, becoming digital; a new generation of learners; the emergence of new instructional technologies; and the accelerating rate of change, especially related to technology. The working group developed five recommendations that academic health leaders and policy makers may use as a starting point for dealing with the instructional technology challenges facing medical education over the next decade. These recommendations are (1) using technology to provide/support experiences for learners that are not otherwise possible-not as a replacement for, but as a supplement to, face-to-face experiences, (2) focusing on fundamental principles of teaching and learning rather than learning specific technologies in isolation, (3) allocating a variety of resources to support the appropriate use of instructional technologies, (4) supporting faculty members as they adopt new technologies, and (5) providing funding and leadership to enhance electronic infrastructure to facilitate sharing of resources and instructional ideas.

The qualities and skills of exemplary pediatric hospitalist educators: a qualitative study.

Purpose To identify the qualities and skills of exemplary and ideal pediatric hospitalist educators. Method The authors conducted a prospective, multi-institutional qualitative study from November 2008 through January 2009 in which they interviewed pediatric hospitalists who were identified as exemplary educators at three academic pediatric residency programs. They then conducted focus groups with residents and medical students who had recently worked with these hospitalists. Qualitative analysis was used to identify themes. Results All six hospitalists identified as exemplary participated. Among invited learners, 14/18 residents (78%) and 16/18 medical students (89%) participated. Together, the participants contributed 266 comments, which the authors categorized into 36 themes within the four domains of teaching skills, personal qualities, patient care skills, and role modeling. New qualities and skills—including self-reflection/insight, encouraging autonomy, time management, knowledge acquisition, and systems knowledge—and differences in perceptions among hospitalists, residents, and students were identified. Differences between the qualities and skills of actual exemplary hospitalist educators and perceptions of those of an ideal hospitalist educator were also identified. Conclusions Pediatric hospitalists in academic residency programs have unique opportunities to significantly affect the education of medical students and residents. This study validates and expands on prior studies of the qualities and skills needed to be a successful hospitalist educator. Researchers and educators designing faculty development programs to train more successful hospitalist educators may wish to target these qualities and skills as well as the differences in medical student and resident needs.

Diagnosing Diagnostic Error

Diagnostic errors are the most common errors in primary care. Diagnostic errors have been found to be the leading cause of malpractice litigation, accounting for twice as many claims and settled cases as medication errors. Diagnostic error is common, harmful, costly, and very critical to the patient-safety issues in health care. Diagnostic errors have received relatively little attention, however. Of what is known, diagnostic errors are an important source of preventable harm. Focused research in this area is highly needed because the causes of diagnostic errors are subtle and solutions are less obvious than for other types of errors. As opposed to medication errors, where the factors predisposing to their occurrence and the resultant preventive strategies are better defined, the relationship between factors influencing the diagnostic reasoning or decision making and a diagnostic error are not as clear. This may include any failure in timely access to care; elicitation or interpretation of symptoms, signs, or laboratory results, formulation and weighing of differential diagnosis; and timely follow-up and specialty referral or evaluation. The literature reveals that diagnostic errors are often caused by the combination of cognitive errors and system failure. Increased understanding about diagnostic decision making, sources of errors, and applying some existing strategies into clinical practice would help clinicians reduce these types of errors and encourage more optimal diagnostic processes.

System-Related Factors Contributing to Diagnostic Errors

Several studies in primary care, internal medicine, and emergency departments show that rates of errors in test requests and result interpretations are unacceptably high and translate into missed, delayed, or erroneous diagnoses. Ineffective follow-up of diagnostic test results could lead to patient harm if appropriate therapeutic interventions are not delivered in a timely manner. The frequency of system-related factors that contribute directly to diagnostic errors depends on the types and sources of errors involved. Recent studies reveal that the errors and patient harm in the diagnostic testing loop have occurred mainly at the pre- and post-analytic phases, which are directed primarily by clinicians who may have limited expertise in the rapidly expanding field of clinical pathology. These errors may include inappropriate test requests, failure/delay in receiving results, and erroneous interpretation and application of test results to patient care. Efforts to address system-related factors often focus on technical errors in laboratory testing or failures in delivery of intended treatment. System-improvement strategies related to diagnostic errors tend to focus on technical aspects of laboratory medicine or delivery of treatment after completion of the diagnostic process. System failures and cognitive errors, more often than not, coexist and together contribute to the incidents of errors in diagnostic process and in laboratory testing. The use of highly structured hand-off procedures and pre-planned follow-up for any diagnostic test could improve efficiency and reliability of the follow-up process. Many feedback pathways should be established so that providers can learn if or when a diagnosis is changed. Patients can participate in the effort to reduce diagnostic errors. Providers should educate their patients about diagnostic probabilities and uncertainties. The patient-safety strategies focusing on the interface between diagnostic system and therapeutic intervention are strategies that involve both processes to facilitate appropriate follow-up and structural changes, such as the use of electronic tracking systems and patient navigation programs.

Twelve tips for developing, implementing, and sustaining medical education fellowship programs: Building on new trends and solid foundations

Abstract Medical education fellowship programs (MEFPs) are a form of faculty development contributing to an organization’s educational mission and participants’ career development. Building an MEFP requires a systematic design, implementation, and evaluation approach which aligns institutional and individual faculty goals. Implementing an MEFP requires a team of committed individuals who provide expertise, guidance, and mentoring. Qualified MEFP directors should utilize instructional methods that promote individual and institutional short and long term growth. Directors must balance the use of traditional design, implementation, and evaluation methodologies with advancing trends that may support or threaten the acceptability and sustainability of the program. Drawing on the expertise of 28 MEFP directors, we provide twelve tips as a guide to those implementing, sustaining, and/or growing a successful MEFP whose value is demonstrated by its impacts on participants, learners, patients, teaching faculty, institutions, the greater medical education community, and the population’s health.

Case 4: Failure to Thrive and Electrolyte Abnormalities in a 3-year-old Girl

1. Danielle Brown, MD* 2. Lauren Hess, MD* 3. Geeta Singhal, MD, MEd* 1. *Baylor College of Medicine, Texas Children’s Hospital. Houston, TX A 3-year-old girl presents to the emergency department after being referred from a pediatric gastroenterologist for failure to thrive. The girl’s foster mother reports that she has been noticing the child losing weight since she received her custody 7 months earlier. The girl has no significant medical history and, per her biological mother’s report, had been developing normally until the previous year. The biological mother supplies photographs and videos to support this claim; however, recent growth charts cannot be obtained. The only growth charts in the record show her at the 50th percentile for length and the 25th percentile for weight at 6 months of age. The foster mother reports frequent choking while eating but denies fever, headache, cough, abdominal pain, gross motor abnormalities, or changes in appetite. The girl’s weight is 9,000 g (<3rd percentile for age) and height is 33.5 in (85 cm) (1.53rd percentile for age). Her vitals are stable. On physical examination, she is an extremely thin child with very little subcutaneous fat and visible bony prominences. She is pale. Her abdomen is distended and tense but nontender. Her liver is enlarged. All other physical examination findings are normal. The patient is hospitalized. An abdominal ultrasound shows hepatomegaly, with the right lobe of the liver measuring 4.9 in (12.5 cm) in cephalocaudal length. Overnight, she becomes tachycardic to 150 beats/min, tachypneic to 33 breaths/min, and febrile to 100.5°F (38.0°C). Her blood pressure and oxygen saturation level are normal. On examination, she is not in respiratory distress, and her lungs are clear to auscultation without any adventitious sounds. Cardiac examination findings are normal. Laboratory evaluation at …

Creating a medical education enterprise: leveling the playing fields of medical education vs. medical science research within core missions

ABSTRACT Background: Unlike publications of medical science research that are more readily rewarded, clinician-educators’ scholarly achievements are more nebulous and under-recognized. Objective:Create an education enterprise that empowers clinician-educators to engage in a broad range of scholarly activities and produce educational scholarship using strategic approaches to level the playing fields within an organization. Design: The authors analyzed the advantages and disadvantages experienced by medical science researchers vs. clinician educators using Bolman and Deal’s (B&D) four frames of organization (structural, human resource, political, symbolic). The authors then identified organizational approaches and activities that align with each B&D frame and proposed practical strategies to empower clinician-educators in their scholarly endeavors. Results: Our medical education enterprise enhanced the structural frame by creating a decentralized medical education unit, incorporated the human resource component with an endowed chair to support faculty development, leveraged the political model by providing grant supports and expanding venues for scholarship, and enhanced the symbolic frame by endorsing the value of education and public recognition from leaderships. In five years, we saw an increased number of faculty interested in becoming clinician-educators, had an increased number of faculty winning Educational Awards for Excellence and delivering conference presentations, and received 12 of the 15 college-wide awards for educational scholarship. These satisfactory trends reflect early success of our educational enterprise. Conclusions: B&D’s organizational frames can be used to identify strategies for addressing the pressing need to promote and recognize clinician-educators’ scholarship. We realize that our situation is unique in several respects, but this approach is flexible within an institution and transferable to any other institution and its medical education program. Abbreviations: B&D: Bolman and Deal; CRIS: Center for Research, Innovation, and Scholarship; OOR: Office of Research