Diagnostic Errors & Excellence

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Deconstructing the process of thinking - system 1 vs system 2

• Traditional teaching:
  • System 1:
    • Fast
    • Intuitive
    • Often “incorrect”
  • System 2:
    • Slow
    • Deliberate
    • Leads to “accurate” conclusions
• The data behind system 1 vs system 2 thinking comes from research with undergraduate psychology students
• Some research on system 1 vs system 2 in medicine:
  • Experiment 1: What happens when physicians are given diagnostic quandaries, followed by the opportunity to “reconsider” (slow down) their conclusions?
    • Accurate diagnosis improved by 2%
    • Self-assessment is poor
    • More time (slowing down) did not significantly help improve diagnosis
  • Experiment 2: When physicians are put into groups, how do they  come to the most accurate conclusions?
    • Person who states the diagnosis first is most often correct
    • When encouraged to take more time, groups of physicians do not improve in accuracy
  • The problem case-based experiments is that all the information is provided to apply system 1 reasoning to, but in the real-world clinician must gather the information without explicit guidance or cues from case-writing
• System 1 vs. System 2 creates a false dichotomy; both have their place
  • Slowing down is especially important in absorbing and gathering information
    • Experts may have to slow down less and less as they have learned which info is most relevant to gather

Cognitive biases

• Terms used to describe deviations from normative, rational thinking
  • Distinctions between different types of biases are arbitrary
• Experiment: What happened when experts from the Society to Improve Diagnosis in Medicine reviewed resident cases?
  • In cases where the resident was wrong (compared to when the resident was right):
    • Identified 2x as many cognitive biases identified twice as many cognitive biases
      • No agreement about which type of biases were at play across experts
    • Takeway: Identifying biases is not useful in itself
      • May be a tool to open conversation/reflection about mistakes!
      • Language of cognitive biases helps to discuss our errors
      • This language is better used to describe what happened than identify why it did

Case for Knowledge:

• If you do not have the knowledge needed to come to the diagnosis, cognitive “de-biasing” is futile.
  • It’s impossible to organize and consider knowledge that you don’t have
  • Gurpreet Dhaliwal: “Knowledge is king”
• Experts are able to use more experiential knowledge + pattern recognition
  • Advanced physicians can come to a correct diagnosis with minimal info provided
• Experiment: What happens when medical students and cardiologists are given extraneous clinical information along with ECGs?
  • The accuracy of medical students interpreting info decreased markedly
  • There was little to no effect on cardiologist interpretation of info
  • Takeaway: Experts were less susceptible to cognitive biases in these ECG cases
• Chat GPT/AI is a valuable tool that relies solely on pattern recognition
• Experts spend more time in system 1 thinking than system 2

Other everyday practices to decrease errors:

• Checklists:
  • Has to be content-bound
  • Help to address blind spots before errors happen
• Pre-mortem conference
  • Forces learners to anticipate problems + build awareness
• Open communication about uncertainty:
  • Would help discern the level of truth with which something is written in the chart
  • Call to action: How can we have a system-wide approach to communicate uncertainity ?
• Instructional Design:
  • Detailed review of one situation may be less helpful than learning from a variety of case presentations
    • This way, learners are able to recognize discriminating factors underlying different diagnoses
  • Do students learn better using high-tech simulations versus simple case descriptions?
    • Learners can learn just as much with high-tech simulation as simple case descriptions
    • Low tech simulation allows for more repetition per student
• Seeing many cases with feedback and reflection about them helps (not just more cases)

Contributors

Shreya Trivedi, MD, ACP Member – Host / Editor
Alice Kennedy, MD – Editor
Geoff Norman, MD, PhD – Guest Expert
John Hwang, MD – Guest Expert

Reviewers

Justin Choi, MD
Gupreet Dhaliwal, MD
Varun Kishor Phadke, MD
Andrew Parsons, MD
Cindy Fang, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  September 6, 2023

Termination Date: September 5, 2026

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Core IM.  The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates this enduring material (podcast) for .5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .5 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.