Goals and Objectives. A Story. Diagnosis. What do diagnostic errors mean to you? University of Texas Health Science Center at San Antonio

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1 Clinical Reasoning and Diagnostic Errors Dx UTHSA Grand Rounds May 13, 2011 Geeta Singhal, MD, MEd Goals and Objectives To introduce the field of diagnostic errors and to open dialogue about their occurrence 1. Become familiar with literature about diagnostic errors 2. Review some cognitive causes of why diagnostic errors may be made 3. Define teaching/reflection strategies that can be utilized with medical learners What do diagnostic errors mean to you? Diagnosis A Story The most critical of a physician s skills It is every doctor s measure of his abilities; it is the most important ingredient in his professional self image (Croskerry, A Universal Model of Diagnostic Reasoning, Academic Medicine, Vol. 84, No.8, August 2009; Nulund, SB. How We Die: Reflection on Life s Final Chapter. New York, NY: Alfred A Knofp;1994) 1

2 Questions Diagnostic Error These are from a multi-site survey The survey was sent to Baylor Pediatric Faculty, TCPA pediatricians, UT Houston faculty and Cincinnati Children s Hospital and associated community pediatricians ( general and subspecialist pediatricians) A diagnosis that was: Unintentionally delayed (sufficient information was available earlier) Wrong (another diagnosis was made before the correct one) Missed (no diagnosis was ever made) Newer Definition: Misdiagnosis-related harm (Graber, Diagnostic Error in Internal Medicine, Arch Intern Med/Vol 165, July 11, 2005;Newman-toker, D., JAMA 2009) What is the most common type of medical error? What did pediatricians say? A. Diagnosis-Related B. Medication-related C. Monitoring-related (i.e. growth charts, follow-up on chronically ill children) D. Prevention-related (handwashing) E. Surgery-related (B) Medication-related (D) Prevention-related (C) Monitoring-related (A) Diagnosis-related (E) Surgery-related What Does the Literature Say? Once upon a time Limited data, especially in pediatrics Adult medicine: diagnostic error seems to be the most common cause of lawsuits 59% of claims in the ambulatory setting were attributed to diagnostic error (Gandhi, TK., Annals of Internal Medicine, 2006) Lawsuits alleging negligent misdiagnoses are the most prevalent type of claim in the United States (Phillips, RL., Qual Saf Health Care, 2004) This may not be the best way to measure diagnostic error incidence Shawn Ralston is an intern Geeta Singhal is a pediatric hospitalist 2

3 CXR What is the diagnosis? A.Parapneumonic effusion B. Empyema C. Myocarditis D. Hemothorax E. Cardiomyopathy Interstitial infiltrates Left para-pneumonic effusion/empyema What happened? What went wrong? The child was found to be restless, tachypneic, and with an increasing oxygen requirement. Due to scheduling delays in the operating room, the treating physicians decided to pursue an ultrasound - guided thorancentesis. The interventional radiologist aspirated a clear transudate suggestive of congestive heart failure. Cardiologist was called to bedside for a stat echocardiogram that revealed a dilated heart with an EF of 28%. Patient was admitted to CV ICU. Stay Tuned Categories of Diagnostic Errors Visual Error Cognitive errors Inadequate knowledge Data gathering Data interpretation System errors Technical failures/equipment failures Organizational issues No-fault errors Atypical, silent New disease Lack of cooperation A model for cognitive error (Graber, Diagnostic Error in Internal Medicine, Arch Intern Med/Vol 165, July 11, 2005) 3

4 Cognitive Error Cognitive Errors Basis in cognitive psychology About fifty known biases exist They are universal and predictable A failure in rational/logical thought Often due to cognitive/affective biases Known as Cognitive Dispositions to Respond (Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78: ; Elstein, Thinking About Diagnostic Thinking, Advances in Health Science Education, Springer 2009) Availability Bias when a diagnosis is commonly seen and the provider keeps that diagnosis in mind Framing effect Patient was packaged in the ER and alternative diagnoses were not pursued Confirmation bias the team looked for evidence to confirm the diagnosis Premature closure the first diagnosis was accepted Other Examples Base-Rate Neglect: Tendency to ignore rate of disease and look for more exotic diseases (pneumonia or CCAM) Blind Obedience: An individual may stop thinking about a problem when confronted with authority (resident to attending, generalist to a consultant) Premature closure: Reaching a diagnosis and failing to assimilate additional data that contradicts it (UTI or C. diff colitis) What is the most common process breakdown leading to diagnostic error? A. Care not sought in a timely manner by patient/caregiver B. Failure to gather available medical information through history and physical and/or review of previous charts C. Problems with ordering, performance or interpretation of diagnostic/laboratory tests D. Failure to follow up on test results E. Patient/caregiver non-adherence to provider recommended follow-up plan (Croskerry,P.,Geoff,N., Advances in Health Sciences Education, Vol. 14, Supplement ) What did the pediatricians say? What Does the Literature Say? B. Failure to gather medical information through history and physical and/or review of charts A. Care not sought in a timely manner by patient/caregiver D. Failure to follow-up on test results E. Patient/caregiver non-adherence to provider recommended follow-up plan C. Problems with ordering, performance or interpretation of diagnostic/laboratory tests 1. Failure to order an appropriate diagnostic test 2. Failure to create a proper follow-up plan 3. Failure to obtain an adequate history or perform an adequate physical exam 4. Incorrect interpretation of a diagnostic test (Gandhi, TK., Annals of Internal Medicine 2006) 4

5 A morning report What is the diagnosis? 3-week-old infant, vomiting for 1 week, projectile, white/formula, postfeeding, intermittent spitting, no diarrhea, no bloody stool, one bowel movement today, no fever, no congestion, decreased activity today Formula: Enfamil Isomil Nutramigen, 3 oz every 2-3 hours, decreased intake past 2 days, 3 wet-diapers today G 2 P 2, full-term, NSVD, BW 3,200 g, GBS-negative, passed meconium on the first day PE: Temp 36 C, PR 180, RR 55, BP 60/40, SpO 2 95% GA: sleeping, dry lips but moist membranes, pale, good skin turgor HEET: flat fontanelle, normocephalic, atraumatic, normal EOM Resp: mild retractions, no rales, no wheezing Cardio: normal S 1 S 2, no murmur, CR 4 sec Abdomen: no hepatosplenomegaly, no mass, normal BS, no tenderness Neuro: grossly intact CN, normal DTR, no clonus, no stiff neck, negative kernig and brudzinski signs A. Pyloric stenosis B. Severe GERD C. Sepsis D. Inborn error metabolism E. Brain tumor 3-week Pattern A morning recognition report vomiting non-bilious 3-week-old infant, vomiting for 1 weeks, projectile, white/formula, postfeeding, intermittent spitting, no diarrhea, projectile no bloody stool, one bowel movement today, no fever, no congestion, decreased activity today Formula: Enfamil Isomil Nutramigen, 3 oz every 2-3 hours, decreased intake past 2 days, 3 wet-diapers today G 2 P 2, full-term, NSVD, BW 3,200 g, GBS-negative, pass meconium on the first day Must be PE: Temp 36 C, PR 180, RR 55, BP 60/40, SpO pyloric 2 95% stenosis GA: sleeping, dry lip, moist membrane, pale, good skin turgor HEET: flat fontanelle, normocephalic, atraumatic, normal EOM Resp: mild retractions, no rales, no wheezing Cardio: normal S 1 S 2, no murmur, CR 4 sec Abdomen: no hepatosplenomegaly, no mass, normal BS, no tenderness Neuro: grossly intact CN, normal DTR, no clonus, no stiff neck, negative kernig and brudzinski signs Pattern recognition Competing evidence 3-week-old infant, vomiting for 1 weeks, projectile, white/formula, postfeeding, intermittent spitting, no diarrhea, no bloody stool, one bowel movement today, no fever, no congestion, decreased activity today Formula: Enfamil Isomil Nutramigen, 1-week 3 oz every 2-3 hours, decreased intake past 2 days, 3 wet-diapers today vomiting? G 2 P 2, fullterm, NSVD, BW 3,200 g, GBS-negative, pass meconium on the first day Must be PE: Temp 36 C, PR 180, RR 55, BP 60/40, SpO pyloric 2 95% stenosis GA: sleeping, dry lip, moist membrane, pale, good skin turgor HEET: flat fonnatnelle, normocephalic, atraumatic, normal EOM Resp: mild mildly retraction, no rale, no wheez Cardio: normal dehydrated S 1 S 2, no murmur, CR 4 sec Abdomen: no hepatosplenomegaly, no mass, no mass, normal BS, no tenderness Neuro: grossly intact CN, normal DTR, no normal clonus, no BS stiff neck, negative kernig & brudzinski Competing evidence What cognitive factor leads most to diagnostic error? 3-week-old infant, vomiting for 1 weeks, projectile, white/formula, postfeeding, intermittent spitting, no diarrhea, no bloody stool, two bowel movement today, no fever, no congestion Formula: Enfamil Isomil Nutramigen, 3 oz every 2-3 hours, decreased intake Temp past 2 days, 3 wet-diapers today G 2 P 2, fullterm, NSVD, BW 3,200 g, GBS-negative, pass meconium on the 36 C first day Must be PE: Temp 36 C, PR 180, RR 55, BP 60/40, SpO pyloric 2 95% stenosis GA: sleeping, dry lip, moist membrane, pale HEET: flat fonnatnelle, lethargic normocephalic, vs. sleeping atraumatic, normal EOM Resp: mild retraction, no rale, no wheez Cardio: normal S1S2, no murmur, CR 4 sec Abdomen: kussmaul no hepatosplenomegaly, vs. mild retractions no mass, normal BS, no tenderness Neuro: grossly intact CN, normal DTR, no clonus, no stiff neck, neg kernig& brudzinski A. Inadequate data gathering or work-up, such as incomplete history and physical B. Inadequate data assessment such as failure to pursue a correct diagnosis once an initial diagnosis has been made C. Inadequate knowledge base D. Inadequate recognition of critical information previously documented in the chart 5

6 What did the pediatricians say? What Does the Literature Say? A. Inadequate data gathering or work-up B. Inadequate data assessment D. Inadequate recognition of critical information previously documented in the chart C. Inadequate knowledge base 1. Faulty synthesis/ Flawed processing of available information (faulty interpretation of a lab result) 2. Faulty Verification (premature closure) 3. Faulty data gathering (ineffective workup) 4. Inadequate knowledge base (Graber,ML., Diagnostic Error in Internal Medicine, 2005) What diagnoses are most vulnerable to diagnostic error? What did the pediatricians say? A. Appendicitis B. Asthma C. Medication side effects D. Psychiatric disorders E. Viral illness diagnosed as a bacterial illness E. Viral illness diagnosed as a bacterial illness C. Medication side effects D. Psychiatric disorders A. Appendicitis B. Asthma What Does the Literature Say? Irrational & Unexplainable Diagnoses in Emergency Medicine Malpractice Suits (In order of frequency) Meningitis Appendicitis Fractures (humerus, radius/ulna) Testicular torsion Fracture femur Fracture (tiba/fibula) Neurologically impaired newborn Symptoms involving abdomen/pelvis Pneumonia (Selbst, SM., Pediatric Emergency Care, Vol 21, Number 3, March 2005) 6

7 Metacognition Teaching Doctors How to Think Metacognition and Reflective Practice Efficient case presentations System-based solutions It is learning from experience It is thinking about one s own or another s thoughts, feelings and values It is checking your diagnostic thinking for possible biases It is thinking about thinking ( Quirk, ME., Intuition and Metacognition in Medical Education, Keys to Developing Expertise, Springer, NY, NY, 2006) Reflective Practice Critical Thinking Knowing-in-action (use of experience, pattern recognition) Reflection-in-action (thinking on our feet) Reflection-on-action (make sense of an event) Slowing down when you should (expert clinicians recognize when to move from pattern recognition to take time to think about the case) Dual Process of Reasoning Recognize distracting stimuli Be aware of cognitive pitfalls in reasoning Be aware of the critical impact of fatigue and sleep on decision-making Understand the need for monitoring one s own affective state (Schon, The Reflective Practitioner, 1983, NY, NY, Basic Books; Moulton, CE., Academic Medicine, Vol. 82, No. 10) (Croskerry, P., Patient Safety in Emergency Medicine, pp , Philadelphia, PA, 2009) Pattern Recognition i cdnuolt blveiee taht I cluod aulaclty uesdnatnrd what I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy It dseno't mtaetr in waht oerdr the ltteres in a word are, the olny iproamtnt tihng is taht the frsit and lsat ltteer be in the rghit pclae. The rset can be a taotl mses. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Azanmig huh? Yaeh and I awlyas tghuhot slpeling was ipmorantt! Diagnostic Pause! Did I put enough effort toward this differential? Did I omit anything serious/life threatening? Am I about to repeat my past mistakes? Did I have any biases? Does the diagnosis make sense? Let s think outside the box! (Graber, M., Educational Strategies to Reduce Diagnostic Error. Advances in Health Science Education, Vol. 14, Supplement ) 7

8 Cognitive Autopsies Conduct as soon as possible Be well-rested Find a secluded place, free of interruptions Start with the beginning of the day or shift Free-associate fully about the event-recall thoughts and feelings Pay attention to ambient conditions Write everything down Discuss with others and record their comments and observations Review cognitive biases Efficient presentation: A reflection of thought process Data delivery Thoroughness All the data Hx-heavy Data synthesis Selectivity The pivotal data DDx-heavy (Adapted from Croskerry, P.,Advances in Patient Safety, Vol. 2., pp ) What is the best way to decrease diagnostic errors? A. Access to Electronic Medical Records (EMR) B. Diagnostic Decision Support Tools C. Peer review process to review medical records D. Establishing feedback pathways to learn about one s diagnostic errors E. Increasing access to and availability of consultants and experts What did the pediatricians say? 1. Access to EMR 2. Availability of diagnostic decision support tools (Community pediatricians ranked increased access to and availability of consultants second) (p< , unpublished data, Singh, et al) What does the Literature Say? Improve cognition Improve diagnostic reasoning skills Learn to avoid cognitive biases Adopt system solutions to cognitive errors Availability of experts/second opinions Electronic medical records Clinical guidelines, clinical-decision support systems (see reference card) 8

9 Let s Hear From You! Take Home Messages Diagnostic errors exist, are understudied, and much research needs to be done, especially in pediatrics Understanding cognitive biases, metacognition and reflection may help in addressing this issue Teaching strategies can be used to decrease diagnostic errors in our trainees References and Credits Bordage G. Elaborated knowledge: a key to successful diagnostic thinking Acad. Med. 1994, 69: Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med Oct;74(10 Suppl):S Chang RW. The importance of early problem representation during case presentations. Acad. Med. 1998,73:S109-S111. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78: Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41: Ericcson KA. The Cambridge Handbook of Expertise and Expert Performance. Cambridge University Press, New York, NY, 2006 Nendaz MR. Promoting diagnostic problem presentation. Med.Ed. 2002,36: Pines JM. Profiles in patient safety: Confirmation bias in emergency medicine. Academic Emerg Med. 2006;13:90-4 Quirk ME. Intuition and metacognition in medical education: Keys to developing expertise. Springer: New York, NY, Montgomery K. How doctors think: Clinical Judgment and the practice of medicine. Oxford University Press, New York, NY, Drs. Lorin, Drutz, Quinonez, and Thammasitboon 9