Critical thinking
and its impact of patient safety
Pat Croskerry MD, PhD
Patient Safety Officer Course
CPSI, Ottawa April 2011
‘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
This session is a focus on our most
important faculty
How we think
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
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?
How many turtle doves did my true love
send me on the 2nd day of Christmas?
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?
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?
If it takes 5 machines 5 minutes to make
5 widgets, how long would it take 100
machines to make 100 widgets?
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?
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
Answers
A. 30
B. 2
C. 46½ hours
_________________________________
D. The ball costs 5¢ and the bat $1.05
E. 5 minutes
F. 47 days
G. Jack is a lawyer
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
Cognitive Reflective Test
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The test distinguishes intuitive from analytical processing
It tests the ability to resist first response that comes to mind
Of 3428 people tested only 17% got all 3 correct
33% answered all three incorrectly
Frederick 2002 (MIT)
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’
Gigerenzer et al, 2002
What do we know
about decision making?
How well do we
make decisions?
A few examples
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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
Extra-Sensory Perception?
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
How well do we make decisions?
A
review of the
(popular) literature
What factors adversely
affect decision making?
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Biases
Information gaps
Ambient conditions
Context
Availability of resources
Well-being of decision maker
Cognitive loading
Fatigue, sleep deprivation
Healthcare is not rocket science
It’s a lot more complicated…
How might we think more critically?
Critical Thinking
• Knowledge of how we reason and make decisions
• To be able to recognize distracting stimuli, propaganda,
irrelevance
• To know and understand cognitive and affective bias
• Ability to identify, analyze, and challenge assumptions in
arguments
• Ability to recognize deception, deliberate or otherwise
• Capability to assess credibility of information
• Ability to monitor and control own thought processes
• Ability to imagine and explore alternatives
• Understanding of how to effectively work through problems
• Capacity for making effective decisions
We have a new way of looking at
decision making
It can be applied to all decision
making in healthcare
Type 1 and Type 2
processes
(dual process theory)
Cognitive style
Cognitive awareness
Cost
Automaticity
Rate
Reliability
Errors
Effort
Predictive power
Emotional component
Scientific rigour
Type 1
Type 2
(intuitive)
Heuristic
Low
Low
High
Fast
Low
Usually
Low
Low
High
Low
(analytical)
Systematic
High
High
Low
Slow
High
Few
High
High
Low
High
Neuroanatomical correlates
• Type 1 processes: ventromedial prefrontal cortex,
nucleus accumbens, amygdala, and lateral temporal
cortex
• Type 2 processes: prefrontal cortex, hippocampus
and medial temporal lobe, posterior parietal cortex
X4
C2
C3
X3
C1
X4
X2
X1
Type 2 processing
requires effort
(22 to 34 Hz)
PREFRONTAL
CORTEX
PARIETAL CORTEX
MT
V4
Color identification
(60 Hz)
Type 1 processing
automatic and effortless
(35 to 55 Hz)
“Spatial” attention
(25 to 45 Hz)
A schematic model for how
the systems work together
TYPE
1
RECOGNIZED
Patient
Presentation
Pattern
Processor
processes
Pattern
Recognition
Repetition
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RECOGNIZED
TYPE
2
processes
Rational
override
Dysrationalia
override
Calibration
Diagnosis
Type
RECOGNIZED
1
Processes
Patient
Presentation
Pattern
Processor
Pattern
Recognition
Repetition
NOT
RECOGNIZED
Type
2
Processes
Executive
override
T
Dysrationalia
override
Calibration
Diagnosis
RECOGNIZED
System
1
Expertise
Proficiency
Initial
percept
or
problem
Pattern
Processor
Competence
Advanced
Beginner
Novice
NOT
RECOGNIZED
System
2
Calibration
Calibra
Decision
Toggle Function
(Hypothesis Hopping)
Type
RECOGNIZED
1
Processes
Patient
Presentation
Pattern
Processor
Pattern
Recognition
Repetition
NOT
RECOGNIZED
Type
2
Processes
Executive
override
T
Dysrationalia
override
Calibration
Diagnosis
6 Main Features of the Model
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Toggle function
Most errors occur in System 1
Repetitive operations of System 2 >>> 1
System 2 override of System 1
System 1 override of System 2
Cognitive Miser function
BMJ Nov 2010
2005
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’
P 14
2006
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
The power of
Type 1 processes
Swallowing saliva
Would you drink a glass
of your own saliva?
The emotion of disgust (System 1)
overcomes rational input (System 2)
How can we improve decision
making
in healthcare?
You aren’t thinking critically enough, so be more careful
The occasional slap
might wake some people up
Other factors that may acutely
compromise
clinical decision making
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Fatigue
Illness, dysphoria
Sleep deprivation, sleep debt, sleep inertia
Production pressures/RACQITO
Group think
10 things Dual Process Theory can do for us
• Provide a universal model for reasoning and decision making that
embraces all approaches
• Provide a straightforward approach to teaching decision making
• Explain how experience/practice leads to ‘automatic’ behavior
• Explain how impulsive/irrational decision making occurs
• Explain how impulsivity/irrational decisions can be overridden
• Show where cognitive and affective bias occurs
• Explain how fatigue and sleep deprivation cause decision failures
• Predict cognitive miserly behavior
• Predict where weaknesses in the decision making process occur
• Predict fruitful areas for research
How might we think more critically?
Critical Thinking
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Knowledge of how we reason and make decisions
Able to recognize distracting stimuli, propaganda, irrelevance
Recognition of eccentric and sociocentric thinking
Intellectual humility
To know and understand cognitive and affective bias
Able to identify, analyze, and challenge assumptions in arguments
Able to recognize deception, deliberate or otherwise
Capability to assess credibility of information
Ability to monitor and control own thought processes
Ability to imagine and explore alternatives
Understanding of how to effectively work through problems
Capacity for making effective decisions
‘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
Robin Hogarth
Educating Intuition
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Select/create decision–making environment
Improve feedback
Impose circuit breakers
Acknowledge emotions
Explore connections
Accept conflict in choice
Make scientific method intuitive