Recognizing Clinical Reasoning Errors

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Recognizing Clinical Reasoning Errors

• Heidi Chumley, MD
• Associate Professor, Family Medicine

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Session Objectives

• At the end of this session, participants should
  be able to
• Outline the steps of the clinical reasoning
  process.
• Define cognitive dispositions to respond (CDRs)
  and describe several CDRs seen with diagnostic
  reasoning errors.
• Recognize clinical reasoning errors in common
  educational settings.

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Clinical Reasoning

• the cognitive process necessary to evaluate and
  manage a medical problem

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Medical Errors

• 44,000 to 98,000 deaths per year due to medical
  errors
• Many systematic and individual factors contribute
  to medical errors
• Recent attention on cognitive errors (clinical
  reasoning, diagnostic reasoning, decision-making)

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Cognitive Errors
Zhang, JAMIA, 2002
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Cognitive Errors

• Of 301 Malpractice claims, 59 involved
  diagnostic errors that led to poor outcomes
  Gandhi, 2006
• Of patients admitted with 10 days of outpatient
  visit, 10 due to diagnostic error Singh, 2007
• Autopsy series showed 24 missed diagnosis
  Shojania, 2003

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Diagnostic process
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Why are errors made?

• Failure/delay of eliciting information Singh,
  2007
• Suboptimal weighing of critical pieces of
  information from HP Singh, 2007
• Overreliance on diagnostic testing Bordage,
  1999

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Cognitive Dispositions to Respond

• Biases that can lead to diagnostic errors
• Mental shortcuts running amuck
• Croskerry defines 32, Acad Med, 2003 78(8)

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Cognitive Dispositions to Respond

• Information-gathering
• Unpacking
• Availability
• Anchoring
• Premature closure
• System
• Diagnosis momentum
• Feedback sanction
• Triage cueing

• Probability
• Aggregate bias
• Base-rate neglect
• Gender bias
• Gamblers fallacy
• Posterior probability error

Croskerry, 2003
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Information-gathering problems

• Unpacking failure to elicit all relevant
  information
• Availability recent exposure influences
  diagnosis
• Anchoring holding onto a diagnosis after
  receiving contradictory information
• Premature closure accepting a diagnosis before
  it is fully verified

Present at all levels, start watching for these
in students
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Clues to Information-Gathering Problems

• Limited differential diagnosis (unpacking,
  availability)
• Lack of attention to contradictory information
  (anchoring)
• Lack of pertinent negatives (premature closure)

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Diagnostic Errors
Unpacking Availability
Anchoring
Information gathering
Premature closure
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Systems contributions

• Diagnosis momentum early diagnosis by another
  provider is accepted as definite
• Feedback sanction final diagnosis does not
  return to initial decision-maker
• Triage cueing location cues management (seen
  through the lens of the first provider)

Present at all levels, more likely to see in
residents
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Clues to System Contributors

• Lack of primary symptom data (diagnostic
  momentum)
• Inattention to closing the loop (feedback
  sanction)
• Non diagnoses non-cardiac chest pain no
  gynecologic cause for lower abdominal pain
  (triage cueing)

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Probability Pitfalls

• Aggregate bias aggregate data do not apply to
  my patients
• Base-rate neglect ignoring the true prevalence
• Gender bias gender inappropriately colors
  probability
• Gamblers fallacy sequence of same diagnoses
  will not continue
• Posterior probability sequence of same
  diagnoses will continue

Best seen during continuity experiences, residency
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Clues to Probability Pitfalls

• Didnt meet criteria, but I(aggregate)
• Rare diagnoses high on list, increased testing
  (base-rate neglect)
• Comments about probability (Gamblers fallacy,
  posterior probability)

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Two Others

• Representative restraint ruled out because the
  presentation is not typical
• Search satisfying search is called off when
  something is found

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Summing Up

• Reasoning errors are common
• Identifying/naming the CDRs is an important part
  of reflection
• No gold standard for assessing reasoning in our
  learners nothing to replace our conversations
  and helping them think about how they are
  thinking
• Are cognitive errors treatable? Yes

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Questions?