Diagnostic Error: Rethinking Our
Relationship to Wrongness
John Banja, PhD
Center For Ethics
Emory 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
Competent
Adequate
Useful
Informed PROFESSIONAL In control
SELF
Assured
Powerful
Awesome
But this professional self is under
constant attack!
The Remarkably Imperfect
Human Being
• Human cognition is remarkably 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
Long waits to be seen
Phone calls
Many sick patients
Work area design
Dim lighting
Uncertain expectations
Home stress
Unworkable policies
New or unfamiliar procedures
Conflicting priorities
Multi-tasking
Shift work fatigue
Constant interruptions
Need to hurry
Noise
New trainees
Multi-tasking
Violence
Ambiguity
Hunger
Short-staffed
Technology won’t work
Taking short cuts
Pre-occupation
Faulty communication
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
Competent
Adequate
Useful
Informed PROFESSIONAL In control
SELF
Assured
Powerful
Awesome
The Professional Self Under
the Assault of Uncertainty
Incompetent
Inadequate
Stupid
Nonuseful
Humiliated
Shattered
Coming Apart
Disoriented
Not in control
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 selfesteem.
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
• The more knowledgeable I feel myself
physicians can become
to be, the less I rely on decisional aides complacent; the failure rate is
minimal and errors may not come
• “Flawless intellectual reasoning,
to their attention for a variety of
diligent checking for errors and
foolproof environmental safeguarding reasons.” (Berner, 2008)
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) selffocus and self-preoccupation
• Able to recognize importance and
significance of others
• Self-forgetfulness
• Lack of regard for social status
“Rethinking our Relationship
to 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, selfconfident, 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
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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, 18:2953.
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 selfesteem 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)