Teaching Internal Medicine Residents
About Cognitive Bias and Diagnostic
Error
James B. Reilly MD, MS, FACP
Diagnostic Errors in Medicine
Objectives
• Describe a longitudinal curriculum for internal
medicine residents in cognitive bias and
diagnostic error
• Present our educational outcomes
• Discuss strengths, limitations and lessons
learned from our experience
• Propose next steps for future educational
innovation and research
Background
• Patient Safety Education in Graduate Medical
Education is systems-focused
• Teaching about Cognitive Bias as a contributor
to diagnostic error is a nascent field
• Previous educational studies have been:
– Single session
– Medical Students >>> Residents
– Grounded in hypothetical cases
– Slower to utilize multimedia approaches
Longitudinal Curriculum in
Cognitive Bias and Diagnostic Errors
SESSION 1
SESSION 2
SESSION 3
40 Minute
Didactic
10 Minute
Review
Web
Curriculum:
20 Minute
Facilitated
Case-Based
Discussion
(RCA)
50 Minute
Narrative
Reflection &
Group
Discussion
Diagnostic
RCA
June 2010
Oct 2010
Case: Bias
Recognition
May – Sep 2011
Longitudinal Curriculum in
Cognitive Bias and Diagnostic Errors
SESSION 1
SESSION 2
SESSION 3
40 Minute
Didactic
10 Minute
Review
Web
Curriculum:
20 Minute
Facilitated
Case-Based
Discussion
(RCA)
50 Minute
Narrative
Reflection &
Group
Discussion
Diagnostic
RCA
June 2010
1.
2.
3.
Oct 2010
Case: Bias
Recognition
May – Sep 2011
SESSION 1 OBJECTIVES
Appreciate the impact of diagnostic errors in medicine
Differentiate systems errors from cognitive errors
Identify common biases
Longitudinal Curriculum in
Cognitive Bias and Diagnostic Errors
SESSION 1
SESSION 2
SESSION 3
40 Minute
Didactic
10 Minute
Review
Web
Curriculum:
20 Minute
Facilitated
Case-Based
Discussion
(RCA)
50 Minute
Narrative
Reflection &
Group
Discussion
Diagnostic
RCA
June 2010
•
•
Oct 2010
Case: Bias
Recognition
May – Sep 2011
SESSION 2 OBJECTIVES
Reflect upon a case in which MD cognitive bias impacted patient
Discuss why the error may have occurred and future prevention
strategies
Longitudinal Curriculum in
Cognitive Bias and Diagnostic Errors
SESSION 1
SESSION 2
SESSION 3
40 Minute
Didactic
10 Minute
Review
Web
Curriculum:
20 Minute
Facilitated
Case-Based
Discussion
(RCA)
50 Minute
Narrative
Reflection &
Group
Discussion
Diagnostic
RCA
Case: Bias
Recognition
Oct 2010
May– Sep 2011
June 2010
•
•
SESSION 3 OBJECTIVES
Identify and differentiate systems from cognitive errors with
diagnostic error fishbone diagram
Recognize cognitive bias in videotaped, simulated clinical scenarios
“Diagnostic Error Fishbone”
Example Factors:
A =The diagnosis of CHF “stuck” after the Emergency Room used it in their clinical
presentation to the medicine housestaff
B =There was a delay in obtaining the home medication list
Results
• Thirty-eight PGY-2 Residents completed all 3 sessions
• Knowledge Assessment:
– Post-curriculum mean 9.26 vs. 8.26 pre-curriculum
• p = 0.006
– Contemporary 3rd year controls scored 7.69
• p < 0.001
• Bias Identification and Suggestion of De-biasing
strategies in response to video cases
– 100% identified at least one bias seen in the video
• 95% identified two, and 65% identified three or more
– 100% suggested at least one appropriate de-bias strategy
• 97% suggested two, and 61% suggested three or more
Question 8:
A 58 year old female with diabetes presents to the ED in with SOB upper
respiratory symptoms. The triage nurse takes the patient’s vital signs and
places her in a room, informing the doctor of “another patient with the
flu.” The patient reports that she has been drinking plenty of fluids and
taking aspirin, to treat her symptoms. On exam, she is not hypoxic, her
lungs are clear, but she is noted to be tachypneic (RR 30). Labs are normal
with only slightly decreased bicarbonate of 18. She is admitted to
medicine for supportive care for presumed viral pneumonia. Further work
up revealed aspirin toxicity. Which of the following is the most likely
reason for the missed diagnosis?
a. Serum HCO3 levels in the ED are often inaccurate and the physician
assumed this was an inaccurate reading.
b. The physician’s lack of knowledge of the presenting symptoms of salicylate
toxicity
c. The physician relied on his experiences with seasonal patterns of illness to
make diagnoses of common syndromes
d. The syndromes of salicylate toxicity and viral pneumonia are often so
similar as to make occasional misdiagnosis inevitable.
Cognitive Biases Recognized by Residents
Cognitive Bias
Anchoring
Availability
Framing Effect
Blind Obedience
Unpacking
Confirmation
Diag. Momentum
Visceral bias
%
87.8%
75.6%
56.1%
53.7%
53.7%
48.8%
48.8%
48.8%
Ogdie AR, Reilly JB, et al. Acad Med 2012
Anchoring
“Once she came in, we had an
impression of her…it was this giant
bias in the room…if he’s got this huge
lung cancer, chest pain in a cancer
patient with a lung primary is
probably going to be cancer pain.”
Blind Obedience
“I think I fell into that bias initially in
that I deferred to authority probably
for too long and I should’ve been
more aggressive in pushing for what I
felt the patient needed to have
done…”
The Importance of Context
Night Float
Anchoring
Availability
Specialty
Service
Framing
Effect
Blind
Obediance
Lack of
Confidence
Hierarchy
Chronic
Illness
Unpacking
Principle
Handoff
Vague
History
Too busy
Diagnostic
Momentum
Too many
patients
Confirmation
Bias
Transfer
Consultants
Integral
Ogdie AR, Reilly JB, et al. Acad Med 2012
Provider
Fatigue
Visceral Bias
Provider
Disinterest
Challenges
• Knowledge assessment
• Faculty Development
• Getting Time in a busy residency curriculum
• Technical Aspects of Web Curriculum
Lessons Learned: Tips for GME…
• Think Big, Start Small
• Be Opportunistic
• Anticipate resistance from the learners (and faculty!)
• Appreciate the importance of context on thinking
• Engage other faculty
Next Steps
• Refine and validate assessment tool
• Disseminate Web Module
• Devise/test educational strategies that can be
incorporated into the clinical environment
• Collaborate
Acknowledgements
•
•
•
•
•
•
Jen Myers, MD
Alexis Ogdie, MD
Joan von Feldt, MD MEd.
Lisa Bellini, MD
Penn IM Residents
Amanda Lerman, MD
– “Dr. Quick”
• Lauren Weinberger, MD
– “ED Attending”
• Jen Kogan, MD
– “Dr. Rush”
• Our Faculty Group
Leaders
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–
–
–
–
–
–
–
Matt Rusk
Todd Barton
Karen Warburton
Jeff Greenblatt
Dave Aizenberg
Steve Kim
Jodi Lenko
Steve Gluckman