Diagnostic errors in medicine are pervasive as described in the recent NAM study (1) and are likely to affect almost all patients over the course of a lifetime.
- It is estimated that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
- Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths.
- Medical record reviews suggest that they account for 6 to 17 percent of adverse events in hospitals.
Cognitive bias has been shown to play a large role in misdiagnosis including confirmation bias, anchoring bias, premature closure and availability bias. A small study entitled, Raising awareness of cognitive biases during diagnostic reasoning, from the Netherlands, (2), looked at cognitive bias as a source for diagnostic errors and explored an intervention to mitigate bias. The study was done on 12 students separated into two groups and presented with a clinical case with salient distractors introduced. The study stressed the need for awareness of bias which leads to life threatening errors. More important the study highlighted the effectiveness of experiential learning to lessen the impact in the future. The NAM report recommendations specifically mention the need for additional training for clinicians.
The literature on interventions to minimize cognitive bias is highly mixed with no consistent techniques established to create sustained changes in clinicians' diagnostic reasoning which minimize bias. Didactic lectures have been shown to have no significant impact on debiasing (3). The techniques researched by Itiel Dror, PhD., a Harvard trained behavioral psychologist, have emphasized the need for neurocognitively aware interventions. He advocates the use of technology, gamification and specifically designed heuristic and progressive dialectic techniques to educate to create sustained behavioral change.
The explanation is clear from our own experiences. Repeatedly telling a child to not touch a hot stove can seem futile. The first experiential lesson which involves touching and burning ones finger, forever changes the child's behavior. It is a basic Skinnerian principle of behaviorism. Likewise in clinical medicine, physicians always remember the missed cases and redouble efforts to not make the same mistake twice. Using the best training we can hopefully avoid the need to burns one finger or miss a patient's diagnosis to train caregivers.
Multiple fields have examined the difficulty finding interventions which create sustained changes in human behavior. The literature is replete in the business world on change management, in the engineering world in human factors engineering and in the medical literature in implementation science showing very high failure rates. The use of technology and neurocognitively aware techniques fortunately have applicability in multiple fields and a cooperative multidisciplinary intervention will certainly have a profound impact on minimizing errors.
We now are exploring the newest techniques and training with the use of technology and simulation to have a meaningful impact on decreasing diagnostic errors. Fortunately progress in electronic decision support for caregivers is also progressing rapidly. The following techniques hold promise and can be introduced today.
- Use experiential learning with simulation
- Train using heuristic and progressive dialectical techniques
- Use technology including gamification with exaggeration
- Provide direct feedback in real-time
- Engage clinicians when training to establish buy in and ownership
- Use electronic decision support with a well designed user interface to help diagnostic efforts.
With these advances hopefully we can alleviate suffering and provide enhanced diagnostic services to our patients.
1 Institute of Medicine. Improving diagnosis in health care. Washington, DC: National Academies of Sciences, Engineering, and Medicine, 2015 (http://iom.nationalacademies.org/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx)
2 van Geene K ; de Groot E ; Erkelens C; et al. Raising awareness of cognitive biases during diagnostic reasoning. Perspect Med Educ. 2016; 5: 182-185
3 Kenyon T, Beaulac G. Critical thinking education and debiasing. Informal Log. 2014;34:341–63.
Nicolas Argy, MD, JD
Copyright © 2016 Nicolas Argy