Diagnostic Error: Rethinking Our Relationship to Wrongness

John Banja, PhDCenter For EthicsEmory University

jbanja@emory.edu

Why Be Interested in Diagnostic Error?

• Diagnostic errors are the leading cause of medical malpractice suits: 45% of cases

• Physicians profoundly underestimate their rates of diagnostic errors: What do you think yours is?

• Health systems unappreciative of the problem

Common DE Scenarios• Dr. Banja examines a patient but:

– Fails to order a diagnostic test that 99 out of 100 physicians would say he should have ordered (or he orders a wrong/irrelevant test)

– Orders a correct diagnostic test but the test is never performed (or it is performed but the results are lost)

– Orders a diagnostic test, the test is performed, but Banja never reads the results (or learns the results too late because the findings are lost or delayed)

– Orders the diagnostic test, it is performed, Banja reads the results, but fails to appreciate their implications; because of that he fails to develop an appropriate treatment plan, saying instead, “You’re fine, Mrs. Smith. Nothing to worry about.”

Diagnostic errors are unappreciated because:

• We have very poor feedback mechanisms that fail to alert physicians to diagnostic errors and their rates

• Many patients have self-limiting ailments from which they recover despite diagnostic error

• Sometimes the diagnosis is wrong but the treatment is nevertheless curative; alternatively, sometimes you don’t have to make the correct diagnosis for the patient to get appropriate care

• Patient sees another physician who makes the correct diagnosis and treats accordingly

• Patient dies from diagnostic error and the erring physician never learns about it

Strategies to reduce DEs• Metacognitive

training/failed heuristics• Computer based decision

supports• Autopsies• Improving systems (test

ordering, specimen processing, test performance, interpretation, follow-up, poor standardization of processes)

• Better feedback processes• More patient involvement• Better medical education• Better history and physical

examination

The goal: “To rethink our relationship to wrongness.”(p.121)

Leon Festinger: Cognitive Dissonance• CD is an

uncomfortable feeling caused by holding two contradictory ideas simultaneously;

• What happens when a very deep-seated belief is disconfirmed by new data?

The Problem of Ideological Transformation

Mark Bertolini, the unconventional chief executive of Aetna, the health insurer, gave thousands of the lowest-paid employees a 33 percent raise, and he has introduced popular yoga classes. His discussions were influenced, in part, by a near-fatal ski accident.

Fundamental Beliefs are …

• Our navigational tools• Make meaning and

sense of our experiences and the world

• Provide the most basic and fundamental directions for our beliefs, feelings, and behaviors

THEY ARE PROFOUNDLY SELF-DEFINING!

And this is the Self Professionals Want

PROFESSIONALSELF

Adequate

Competent

Useful

Informed In control

Assured Powerful

Awesome

But this professional self is under constant attack!

The Remarkably Imperfect Human Being

• Human cognition is re-markably fallible: slips, lapses, mistakes, unintentional as well as intentional variations of standard processes, faulty reasoning, prone to implementing biases (e.g., availability, confirmation, anchoring, etc.) leading to error, etc.

Here’s an example

TEST QUESTION

• A baseball bat and a baseball together cost $1.10.

• The bat costs $1 more than the ball.

• How much does each item cost?

The question …..

• Was circulated among undergraduates at Ivy League Universities and at Public Universities:– ~ 50% of the IVY

League students got it wrong.

– > 50% of the Public University students got it wrong.

Once again…

• A baseball bat and a baseball together cost $1.10.

• The bat costs $1 more than the ball.

• How much does each item cost?

The correct answer is….• The bat costs $1.05 • The ball costs $.05• If you said the bat

costs $1.00 and the ball costs $.10, then the bat would cost $.90 more than the ball. But you were told the bat costs $1 more.

Add to that the Degraded Work Environment

Work area design

Faulty communication

New or unfamiliar procedures

Multi-tasking

Shift work fatigue

Constant interruptions

Phone calls

Pre-occupationNeed to hurry

Long waits to be seen

Dim lighting

Noise

Many sick patients

Home stress

Uncertain expectations

Violence

Short-staffed

Multi-tasking

Technology won’t work

Ambiguity

New trainees

Hunger

Taking short cuts

Conflicting priorities

Unworkable policies

And not only that but……• Unpredictable and dynamic environments• Multiple sources of concurrent information (with

varying accuracies)• Reliance on indirect or inferred indications (e.g.,

judgment calls)• Actions having multiple consequences• High stress• Complex human to machine interfaces• Multiple players with varying levels of

competence and familiarity• High stakes that may compromise risk awareness

and risk aversiveness

And add to that…..• “Do you people really

know what you’re doing here?”

• “I’ve got WHAT?????”• “Are you licensed?” • “Let me tell you

something….”• “Oh God, this can’t be

happening to me….”• “Oh, I hurt so much…why

can’t you do something?”• “How much time do I

have?”

Feelings, feelings, feelings…..

• “Our first response to anything is an affective one that governs the future direction of our relations.” (Croskerry, 2008a)

“[V]irtually every image, actually perceived or recalled, is accompanied by some reaction from the apparatus of emotion.” (58)

“[E]ven when we “merely” think about an object, we tend to reconstruct memories not just of a shape or color but also of the…accompanying emotional reactions, regardless of how slight…You simply cannot escape the affectation of your organism, motor and emotional most of all, that is part and parcel of having a mind.” (FWH, 148)

How is John doing?

Feelings, feelings, feelings…..

• “Our first response to anything is an affective one that governs the future direction of our relations behaviors.” (Croskerry, 2008a)

Application to Diagnostic Error

The goal: “To rethink our relationship to wrongness.” (p.121)

The Encounter With Uncertainty in a Clinical Context

• Behavioral: Stymied, paralyzed, incapacitated, unable to move forward;

• Cognitive: Cannot assign outcome probabilities confidently; cannot plan or envision a course of action or a treatment plan;

• Affective: Anxiety, feeling lost, helpless, disoriented, etc.

• “It is considered a weakness and a sign of vulnerability for clinicians to appear unsure. Confidence is valued over uncertainty, and there is a prevailing censure against disclosing uncertainty to patients.” Croskerry 2008b)

The Professional Self

PROFESSIONALSELF

Adequate

Competent

Useful

Informed In control

Assured Powerful

Awesome

The Professional Self Under the Assault of Uncertainty

HumiliatedShattered

Coming Apart

Inadequate

Incompetent

Nonuseful

Stupid Not in control

Disoriented Powerless

Worthless

Antidote: Overconfidence• “Overconfidence results at times

from a desire to see the self as a competent or accurate perceiver…undue confidence often arises when uncertainty would challenge valued beliefs about the self as knowledgeable and competent…the motive to see the self as competent leads to less critical analyses of the true ability levels during confidence assessments…our participants were motivated to protect themselves from the implications of feeling uncertain.” (Blanton, 2001)

• “Most efforts to reduce overconfidence have failed.” (Arkes, 1987)

Me? Screw Up? Get outta here..

• “Overconfidence can impart a false sense of security” (Bauman, 1991)

• When Graber asked physicians whether they made a diagnostic error in the past year, only 1% admitted it. “The concept that they, personally, could err at a significant rate is inconceivable to most physicians….Physicians acknowledge the possibility of error, but believe that mistakes are made by others.” (Berner, 2008)

The Fundamental Problem of Overconfidence

• Overconfidence becomes a replacement or substitute for failing to look for more evidence, for not seeking more feedback, etc.

• Instead of accepting my uncertainty and managing it constructively, I resist it and compensate for it by cultivating powerful feelings of being right that soothe my self-esteem.

Overconfidence and the Pragmatics of Medicine • Humans are not Bayesian thinkers,

but have evolved (fast and frugal) cognitive biases for reasons of neurological efficiency (biological mutations were easier to produce), response speed, and the adaptive challenges in the survival landscape.

• Biases allow agents to make effective (i.e., uncostly, adaptive) decisions with less information

• Fast and frugal decisionmaking “succeed so reliably that physicians can become complacent; the failure rate is minimal and errors may not come to their attention for a variety of reasons.” (Berner, 2008)

• The more knowledgeable I feel myself to be, the less I rely on decisional aides

• “Flawless intellectual reasoning, diligent checking for errors and foolproof environmental safeguarding would require superhuman talent.” (Redelmeier, 2001)

And the longer you are in practice… • “Physicians with many

years of clinical practice may be even more susceptible to availability bias than second-year residents.” (Mamede, 2010)

• “Increased experience was associated with decreased likelihood of requesting second opinions, curbside consultations, and reference materials, regardless of diagnostic accuracy.” (Meyer, 2013)

So, is this physician overconfident?

• No: not so long as his clinical discernment and judgment are “reasonable,” i.e., comply with the professional standard.

• Also: When you hear the sound of hooves….etc.

The Problem is when….• That nagging feeling of

uncertainty enters the picture

• The question: When should I get support/help:– Metacognitive

training/failed heuristics? (Am I in denial? Rationalizing?)

– Computer based decision supports?

– Autopsy?– Do homework on this one?– Greater skill development?

(Improving history and physical? Improving test interpretation or following)

Poor Feedback Increased Confidence • “In the absence of …

clear feedback, physicians feel little need to update their current Diagnostic Schema. Thus a felt need for Updating declines and Confidence increases. As Confidence increases the felt need for Updating decreases further in a reinforcing cycle.” (Rudolph, 2008)

Changing the deep-seated beliefs and practices may require divine intervention

• “Physicians are slowly being convinced that fallibility is the human condition, and most readily acknowledge slips and lapses, but seasoned practitioners have lingering doubts that their own reasoning could be flawed…[R]estatement of compelling evidence has never been a sufficient force to change established clinician behavior… change may represent a midbrain event more than a cortical event.” (Miles, 2007)

• “[D]ebiasing will probably require multiple interventions and lifelong maintenance.” (Croskerry, 2013)

Unhealthy Humility Prototype• Servility• Obsequiousness• Groveling• Low self-esteem• Feelings of shame• A brake on immoderate

ambition (Thomas Aquinas)• Bernard (“On Humility and

Pride”):– Quiet and restrained speech– Keeping silent unless asked

to speak– Thinking oneself unworthy to

take initiative– Desiring no freedom to

exercise one’s will

“Healthy” Humility Prototype, i.e., Optimal Self-Calibration

• Accurate self-opinion (doesn’t distort self-information for narcissistic needs)

• Keeping one’s talents in perspective• Self-acceptance and understanding

one’s imperfections; no need to see myself as superior

• Freedom from arrogance• Freedom from low self-esteem• Willingness to admit mistakes• Contrition for one’s shortcomings• Lack of (and relief from) self-focus

and self-preoccupation• Able to recognize importance and

significance of others• Self-forgetfulness• Lack of regard for social status

“Rethinking our Relationshipto Wrongness” and Mid-Brain Changes

• Acknowledge lack of feedback mechanisms• Accept importance of diagnostic error• Actively discuss diagnostic challenges• Discuss diagnostic error early in the education of medical

students• Allow medical students and residents to openly question

diagnostic decisions, verbalize their own diagnostic reasoning, and receive constructive feedback

• Ask “What do I not want to miss?”• Implement a system to automatically screen patients

returning to the ED within 48 hours• Special consideration for symptom presentations at elevated

risk for error

Diagnostic Error (Humility) Measures from the Pennsylvania Safety Authority (25A)

• Request second opinions• Request diagnostic feedback from colleagues• Notify referring physicians when diagnoses of referral

patients are modified• Disclose diagnosis to patients early, then refine/modify

with patient involvement• Survey past patients to see if diagnostic error occurred• Educate and involve patients in the diagnostic process • Create reliable feedback loops• Monitor diagnostic error rates

Humility Strategies

• “…openness toward reflection that would allow for better toleration of uncertainty… making error visible…provide expert consultations.” (Berner, 2008)

• “[T]he motive to boost confidence may be attenuated if a person is first given opportunities to lower the importance of feeling knowledgeable.” (Blanton, 2001)

• “[O]ur participants were motivated to protect themselves from the implications of feeling uncertain...one of the best ways to decrease overconfidence may be to decrease the threat inherent in admitting ignorance.” (Blanton, 2001)

Looking for humility in medicine: Jennifer Arnold, MD

• Born with skeletal dysplasia (spondyloepiphyseal dysplasia)

• Has undergone >30 surgeries

• MD graduate from Hopkins in 2000; board certified in pediatric and neonatal medicine

Arnold on Humility (Commencement Speech to the MD Graduates

at UTMB Galveston 2012) • “[A]cademic medicine and the media support arrogance,

assertiveness, and even entitlement. As a medical student you had to overcome numerous intellectual, emotional, social and economic challenges to become a physician. The hidden curriculum of medical education promotes egoism, “I paid my dues, so now I am entitled to….” We are surrounded by personifications of physicians in the media that promote this as well. Television and film promote doctors who know it all (House, MD) or who are sexy, self-confident, and always take charge in the operating room (Grey’s Anatomy). Patients come to you looking for answers, treatment, expertise, and even miracles. Yet, when we don’t know all the answers we are afraid to admit to our limitations.”

Factors militating against humility• “[W]e propose that humility would be unlikely to stem from

parenting or educational styles that involve (a) an extreme emphasis on performance, appearance, popularity, or other external sources of self-evaluation, particularly if combined with perfectionist performance standards; (b) inaccurate, excessive praise or criticism; (c) frequent comparison of the child against siblings or peers, especially if this comparison is accompanied by competitive messages; and (d) communicating to the child that he or she is superior or inferior to other people. Such practices would predispose a child to turn to external sources of validation for a sense of security, and they would also encourage the child to make competitive, invidious comparisons.” (Peterson, 2004)

Fostering Humility: How difficult it is

• Exposure to different peoples and cultures

• Life threatening illness

• Serious accident• Birth of a child• Dissolution of a

marriage• Religious beliefs• Transcendental

experiences

Future directions and challenges

• In what specific domains is a sense of humility adaptive and by what mechanisms?

• Are there circumstances in which humility can be a liability?

• How can parents, teachers, and therapists foster an adaptive sense of humility?

• “The difference between the expert and the amateur consists in the fact that when the expert commits error, he or she is often able to make an heroic recovery.” (James Reason, Human Error.)

The goal: “To rethink our relationship to wrongness. (121)”

References

References• Arkes, H.R., et al. 1987. Two methods of reducing overconfidence. Organizational

Behavior and Human Decision Processes, 39, 133-144.• Baumann, A.O., et al. 1991. Overconfidence among physicians and nurses: the micro-

certainty, macro-uncertainty phenomenon. Social Science Medicine, 32(2):167-174.• Berner, E.S., and M.L. Graber. 2008. Overconfidence as a cause of diagnostic error in

medicine. American Journal of Medicine, 121(5A):S2-S23.• Blanton, H., et al. 2001. Overconfidence as dissonance reduction. Journal of

Experimental Social Psychology, 37:373-385.• Croskerry, P. 2013. from mindless to mindful practice—cognitive bias and clinical

decision making. New England Journal of Medicine, 368(26):2445-2448.• Croskerry, P., A.A. Abbass, A.W. Wu. 2008a. How doctors feel: affective issues in

patients’ safety. The Lancet, 372: 1205-1206.• Croskerry, P., and G. Norman. 2008b. Overconfidence in clinical decision making.

American Journal of Medicine, 121, (5A):S24-S29. • Damasio, A. 1999. The Feeling of What Happens. New York: Harcourt Brace and

Company.• Ende, J. 1983. Feedback in clinical medical education. JAMA, 250(6):777-781.• Graber, M.L., N. Franklin, and R. Gordon. 2005. Diagnostic error in internal medicine.

Archives of Internal Medicine, 165:1493-1499.

References continued• Mamede, S., et al. 2010. Effect of availability bias and reflective reasoning on diagnostic

accuracy among internal medicine residents. 304(11):1198-1203.• Meyer, A.N., et al. 2013. Physicians’ diagnostic accuracy, confidence, and resource

requests. JAMA Internal Medicine, 173(21):1952-1959.• Miles, R.W. 2007. Fallacious reasoning and complexity as root causes of clinical inertia.

Journal of the American Medical Medical Directors Association, 8:349-354.• Pennsylvania Patient Safety Advisory. 2010. Diagnostic error in acute care, 7(3):76-86.• Peterson, C., and M. Seligman. 2004. Humility and modesty, in Character Strengths and

Virtues: A Handbook and Classification. New York: Oxford, pp. 461-475.• Redelmeier, D.A., et al. 2001. Problems for clinical judgement: introducing cognitive

psychology as one more basic science. Canadian Medical Association Journal, 164(3):358-360.

• Rudolph, J.W., and J.B. Morrison. 2008. Sidestepping superstitious learning, ambiguity, and other roadblocks: a feedback model of diagnostic problem solving. American Journal of Medicine, 121(5A):S34-S37.

• Sieck, W.R., and H. Arkes. 2005. The recalcitrance of overconfidence and aits contribution to decision aid neglect. Journal of Behavioral Decision Making, 18:29-53.

• Tangney, J.P. 2009. Humility, in S.J. Lopez and C.R. Snyder (eds.), The Oxford Handbook of Positive Psychology, 2nd ed. Available online.

• Wikipedia. 2014. Overconfidence effect. Available at http://en.wikipedia.org/wiki/Overconfidence_effect.

• “Overconfidence can be beneficial to individual self-esteem as well as giving an individual the will to succeed in their desired goal. Just believing in oneself may give one the will to take one’s endeavors further than those who do not.” (Wikipedia, 2014)

• System 1 intuitive thinking may be associated with strong emotions such as excitement and enthusiasm. Such positive feelings, in turn, have been linked with an enhanced level of confidence in the decision maker’s own judgment” (Croskerry, 2008b)

Humility: from humus, “one’s condition of being flatly on the ground”

• May be a relatively rare human characteristic and antithetical to human nature

• The self is remarkably resourceful at accentuating the positive and deflecting the negative

• “Self-enhancement biases” are pervasive (Tangney, 2009)