Teaching Internal Medicine Residents About Cognitive Bias and Diagnostic Error

1. Teaching Internal Medicine Residents About Cognitive Bias and Diagnostic Error James B. Reilly MD, MS, FACP Diagnostic Errors in Medicine

2. 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

3. 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

4. Longitudinal Curriculum in Cognitive Bias and Diagnostic Errors SESSION 1 SESSION 2 SESSION 3 40 Minute Didactic 20 Minute Facilitated Case-Based Discussion (RCA) 10 Minute Review 50 Minute Narrative Reflection & Group Discussion Web Curriculum: Diagnostic RCA Case: Bias Recognition June 2010 Oct 2010 May – Sep 2011

5. Longitudinal Curriculum in Cognitive Bias and Diagnostic Errors SESSION 1 SESSION 2 SESSION 3 40 Minute Didactic 20 Minute Facilitated Case-Based Discussion (RCA) 10 Minute Review 50 Minute Narrative Reflection & Group Discussion Web Curriculum: Diagnostic RCA Case: Bias Recognition June 2010 Oct 2010 May – Sep 2011 SESSION 1 OBJECTIVES Appreciate the impact of diagnostic errors in medicine Differentiate systems errors from cognitive errors Identify common biases

6. Longitudinal Curriculum in Cognitive Bias and Diagnostic Errors SESSION 1 SESSION 2 SESSION 3 40 Minute Didactic 20 Minute Facilitated Case-Based Discussion (RCA) 10 Minute Review 50 Minute Narrative Reflection & Group Discussion Web Curriculum: Diagnostic RCA Case: Bias Recognition June 2010 Oct 2010 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

7. Longitudinal Curriculum in Cognitive Bias and Diagnostic Errors SESSION 1 SESSION 2 SESSION 3 40 Minute Didactic 20 Minute Facilitated Case-Based Discussion (RCA) 10 Minute Review 50 Minute Narrative Reflection & Group Discussion Web Curriculum: Diagnostic RCA Case: Bias Recognition June 2010 Oct 2010 May– Sep 2011 SESSION 3 OBJECTIVES • Identify and differentiate systems from cognitive errors with diagnostic error fishbone diagram • Recognize cognitive bias in videotaped, simulated clinical scenarios

8. “Diagnostic Error Fishbone” Example Factors: A =The diagnosis of CHF “stuck” after the Emergency Room used it in their clinical presentation to the medicine housestaffB =There was a delay in obtaining the home medication list

10. 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

11. 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.

12. Cognitive Biases Recognized by Residents Ogdie AR, Reilly JB, et al. Acad Med 2012

13. 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.”

14. 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…”

15. The Importance of Context Chronic Illness Unpacking Principle Night Float Anchoring Availability Handoff Vague History Specialty Service Framing Effect Too busy Diagnostic Momentum Blind Obediance Too many patients Confirmation Bias Lack of Confidence Hierarchy Transfer Provider Fatigue Consultants Integral Visceral Bias Provider Disinterest Ogdie AR, Reilly JB, et al. Acad Med 2012

16. Challenges • Knowledge assessment • Faculty Development • Getting Time in a busy residency curriculum • Technical Aspects of Web Curriculum

17. 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

18. Next Steps • Refine and validate assessment tool • Disseminate Web Module • Devise/test educational strategies that can be incorporated into the clinical environment • Collaborate

19. Our Faculty Group Leaders Matt Rusk Todd Barton Karen Warburton Jeff Greenblatt Dave Aizenberg Steve Kim Jodi Lenko Steve Gluckman 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”