You now have experience developing PICO questions and have learned about different study designs including their strengths and weaknesses. During your clerkship experiences you and your team will have many questions about how to best care for your patients. Throughout your career you will need to seek evidence on best practices to make clinical decisions and will have to sort through journal articles, practice guidelines and evidence summaries to determine how to proceed with diagnostics and therapies. Understanding different ways to appraise literature will help you answer your questions and make decisions based on evidence.
There are many resources available to you through the University of Washington Health Sciences Library to assist in this process.
For a list of sites to search for evidence see http://guides.lib.uw.edu/hsl/ebp
For a refresher on PICO questions see http://guides.lib.uw.edu/hsl/ebp/pico
For this session, please reflect on your case study. Consider possible interventions or therapies that may be beneficial to the patient. Develop a PICO question before the session as you will be reviewing and appraising literature in order to answer this in class.
1) Watch PICO video
GOAL: Differentiate a PICO question from a background question.
Instructions: Actively watch video to help understand the components of a PICO question and how you might employ these questions in clinical practice.
2) Watch Finding Medical Information video
GOAL: Understand how to access different sources of information depending on your question.
Instructions: Actively watch video to help understand differences between types of questions and available resources to answer them.
3) Write some PICO questions of your own
Develop 2-3 PICO question of your own to share in class tomorrow. It may help to think about a patient you have seen or a case discussed during Foundations or EHM so far. You can use the PICO diagramming tool to record your questions. Be prepared to share and discuss.
How are type I and type II thinking at work in the medical decision making process? In this session we explore type I and type II thinking more deeply. How do these processes disadvantage and advantage this process? We find the concepts in cognitive and affective biases in medicine to be useful as constructs and examples. It is not necessary for you to memorize this list. It is important that you are able to recognize how type I and type II thinking are present in each example. Many of our attempts to prevent cognitive errors require us to recognize when we are relying on type I thinking and encourage us to spend time in type II thought. We will also spend time discussing environmental and system factors that can distract and support these processes.
Watch the video Understanding and Preventing Cognitive Errors in Medicine through 10:05.
Read the vocabulary list below.
From: Croskerry, P. 50 cognitive and affective biases in medicine. 2013.
The following 3 are included in the USMLE content list:
Anchoring: the tendency to perceptually lock on to salient features in the patient’s initial presentation too early in the diagnostic process, and failure to adjust this initial impression in the light of later information. This bias may be severely compounded by the confirmation bias.
Availability: the disposition to judge things as being more likely, or frequently occurring, if they readily come to mind. Thus, recent experience with a disease may inflate the likelihood of its being diagnosed. Conversely, if a disease has not been seen for a long time (is less available) it may be under-diagnosed. The availability cascade occurs when a collective belief becomes more plausible through increased repetition, e.g. ‘I’ve heard this from several sources so it must be true’.
Framing effect: how diagnosticians see things may be strongly influenced by the way in which the problem is framed, e.g., physicians’ perceptions of risk to the patient may be strongly influenced by whether the outcome is expressed in terms of the possibility that the patient may die or that they might live. In terms of diagnosis, physicians should be aware of how patients, nurses and other physicians frame potential outcomes and contingencies of the clinical problem to them.
The following cognitive biases may also contribute to faulty decision making and medical errors.
Aggregate bias: when physicians believe that aggregated data, such as those used to develop clinical practice guidelines, do not apply to individual patients (especially their own), they are exhibiting the aggregate fallacy. The belief that their patients are atypical or somehow exceptional, may lead to errors of commission, e.g. ordering x-rays or other tests when guidelines indicate none are required
Base-rate neglect: the tendency to ignore the true prevalence of a disease, either inflating or reducing its base-rate, and distorting Bayesian reasoning. However, in some cases clinicians may (consciously or otherwise) deliberately inflate the likelihood of disease, such as in the strategy of ‘rule out worst case scenario’ to avoid missing a rare but significant diagnosis.
Blind Obedience: showing undue deference to authority or technology. This can occur when an individual or team defers to the opinion of the consultant or to the findings of a radiologic study, even when it doesn’t make sense with the clinical picture.
Blind spot bias: the general belief physicians may have that they are less susceptible to bias than others due, mostly, to the faith they place in their own introspections. This bias appears to be universal across all cultures.
Commission bias: results from the obligation towards beneficence, in that harm to the patient can only be prevented by active intervention. It is the tendency towards action rather than inaction. It is more likely in over-confident physicians. Commission bias is less common than omission bias.
Confirmation bias: the tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it, despite the latter often being more persuasive and definitive.
Diagnosis Momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries, (patients, paramedics, nurses, physicians) what might have started as a possibility gathers increasing momentum until it becomes definite and all other possibilities are excluded.
Fundamental attribution error: the tendency to be judgmental and blame patients for their illnesses (dispositional causes) rather than examine the circumstances (situational factors) that might have been responsible. In particular, psychiatric patients, minorities and other marginalized groups tend to suffer from this bias. Cultural differences exist in terms of the respective weights attributed to dispositional and situational causes.
Information bias: the tendency to believe that the more evidence one can accumulate to support a decision the better. While gathering sufficient information is always important, it is also important to anticipate the value of information and whether it will be useful or not in making the decision, rather than collecting information because we can, or for its own sake, or out of curiosity.
Mere exposure effect: the development of a preference for something simply because you are familiar with it. Also known as the familiarity principle, it can have widespread effects in medicine, e.g., merely seeing a pharmaceutical product or being told about it may increase the likelihood of choosing it over other products.
Need for closure: the bias towards drawing a conclusion or making a verdict about something when it is still not definite. It often occurs in the context of making a diagnosis where the clinician may feel obliged to make a specific diagnosis under conditions of time or social pressure, or to escape feelings of doubt or uncertainty. It might be preferable to say instead that the patient’s complaint is ‘not yet diagnosed’ (NYD).
Omission bias: the tendency towards inaction; rooted in the principle of non-maleficence. In hindsight, events that have occurred through the natural progression of a disease are more acceptable than those that may be attributed directly to the action of the physician. The bias may be sustained by the reinforcement often associated with not doing anything, but may prove disastrous. Omission biases typically outnumber commission biases.
Posterior probability error: occurs when a physician’s estimate for the likelihood of disease is unduly influenced by what has gone before for a particular patient. It is the opposite of the Gambler’s fallacy in that the physician is gambling on the sequence continuing, e.g., if a patient presents to the office five times with a headache and is correctly diagnosed as migraine on each visit, it is the tendency to diagnose migraine on the sixth visit.
Premature closure: is a powerful bias accounting for a high proportion of missed diagnoses. It is the tendency to apply premature closure to the decision making process, accepting a diagnosis before it has been fully verified. The consequences of the bias are reflected in the maxim ‘when the diagnosis is made, the thinking stops’.
Search satisficing: reflects the universal tendency to call off a search once something is found. It is pervasive and considered one of the most important sources of error in radiology. Comorbidities, second foreign bodies, other fractures, and co-ingestants in poisoning may all be missed.
Sunk costs: the more clinicians invest in a particular diagnosis, the less likely they may be to release it and consider alternatives. This is an entrapment form of bias more associated with investment and financial considerations. However, for the diagnostician, the investment of time, mental energy and, for some, ego may be a precious investment. Confirmation bias may be a manifestation of such an unwillingness to let go of a failing diagnosis.
Visceral bias: the influence of affective sources of error on decision-making has been widel underestimated. Visceral arousal leads to poor decisions. Countertransference, involving both negative and positive feelings towards patients, may result in diagnoses being missed.
Zebra retreat: occurs when a rare diagnosis (zebra) figures prominently on the differential diagnosis but the physician retreats from it for various reasons:
Perceived inertia in the system and barriers to obtaining special or costly tests;
• Self-consciousness and under-confidence about entertaining a remote and unusual diagnosis, and gaining a reputation for being esoteric;
• The fear of being seen as unrealistic and wasteful of resources;
• Underestimating or overestimating the base-rate for the diagnosis;
• The clinical environment may be very busy and the anticipated time and effort to pursue the diagnosis might dilute the physician’s conviction;
• Team members may exert coercive pressure to avoid wasting the team’s time;
• Inconvenience of the time of day or weekend and difficulty getting access to specialists;
• Unfamiliarity with the diagnosis might make the physician less likely to go down an unfamiliar road;
• Fatigue, sleep deprivation, or other distractions may tip the physician toward retreat. Any one or a combination of these reasons may result in a failure to pursue the initial hypothesis.
This session begins an exploration of thinking about thinking. Nobel laureate Daniel Kanhneman deserves credit for the title- he published Thinking, Fast and Slow in 2011. In our quest to become master clinicians, it is paramount we explore all aspects of clinical reasoning. This session introduces the thought process behind conscious and unconscious bias and how it may influence the way you think about clinical problems and patients.
A brief note on bias. The Oxford English Dictionary (OED) defines bias as “Cause to feel or show inclination or prejudice for or against someone or something.” As you read the below articles and participate in the in class discussion consider how these theories of thought contribute to how fast or slow you arrive at conclusions.
Over the course of EHM we will continuously refer to Type I and Type II thinking. An understanding of these fundamental thought processes can improve not only your clinical reasoning but your interactions with patients and peers.
Actively watch this introductory video on Dual Process Theory. Compare and contrast system 1 and system 2.
Read entire article, paying particular attention to the highlighted portions. Begin to think about how the 2 systems interplay in clinical decision making and how physicians must rely on both.
Croskerry P. A universal model of diagnostic reasoning. Acad Med. 2009;84:1022-8. Be sure to read the highlighted sections
|Metacognition: Thinking about thinking; Knowing about knowing; Being aware of your awareness.|
- It is a self-regulatory process that monitors and evaluates your own cognitive processes.
- Metacognitive practices help you identify your own strengths, weakness and limitations so that you can identify strategies to expand your knowledge or skill level.
|Reflection is a metacognitive process that occurs before, during and after situations with the purpose of developing greater understanding of both the self and the situation so that future encounters with the situation are informed from previous encounters. (Sandars, 2009)|
- We do not learn from our experiences by simply having them.
- Reflection on action allows us to gain understanding and learning from the experiences we have had.
- The Adult Learning Cycle by Kolb (1984) is one way to conceptualize the steps we take to learn from our experiences. Reflection on action is a key piece.
Figure 1. The adult learning cycle by Kolb. Courtesy of www.infed.org/biblio/b-explrn.htm.
Steps in Adult Learning Cycle:
- You have an experience.
- You reflect back on that experience. You may identify actions you took or reactions you had and the consequences or outcomes.
- You analyze and try to understand why you took those actions and/or where the reactions came. You hypothesize about how they led to the consequences. You think about how you may apply these concepts to other situations and identify any learning needs you may have to close a gap in your knowledge or skills.
- You plan how what you will do next time you are in a similar situation based on your conclusions from Stage 3.
- You take an exam assessing your knowledge of cardiovascular drugs and receive a score below what you expected.
- You reflect on your study strategy which included making flash cards to test yourself on the mechanism of action, half-life and side effects of each medication. The test, however, required you to select appropriate drugs based on clinical scenarios.
- While you are confident with the pharmacokinetics and the mechanism of action of the medications you think you might not have gained a deeper understanding of the down stream effects on the patient’s physiology. You think that understanding drugs at this level will likely be applicable to other systems, as well.
- You make a plan that next time you lean about a drug you will consider how the medication will affect physiology and what the down stream effects may be. You will also identify clinical problems that would be treated or managed by these effects.
- You are taking a history from a teenage girl. During the social history portion, you ask her if she has a boyfriend. She crosses her arms, becomes quiet and participates minimally in the rest of the interview.
- You reflect on the conversation and identify that her behavior and engagement changed when you asked her about the boyfriend. You also recalled that you did not inquire whether she had romantic or sexual relationships with females and wonder if she felt isolated or judged after asking only about male “boyfriend-type” relationships.
- You hypothesize that some people may feel uncomfortable answering closed ended questions with limited presented options. You consider that you may be applying your own or other societal norms to your questions that may feel alienating to the patient.
- You make a plan that next time you are taking a social history, you ask open-ended questions when inquiring about sexual orientation, gender identity, relationships and family structure.
Sandars J. The use of reflection in medical education: AMEE Guide No. 44. Medical Teacher. 2009;31:685-695.
Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development (Vol. 1). Englewood Cliffs, NJ: Prentice-Hall.
This is a partial list of some important terms. For a more complete list, see the Diversity and Inclusion Dictionary.
Diversity: Diversity means more than just acknowledging and/or tolerating difference. Diversity is a set of conscious practices that involve:
- Understanding and appreciating interdependence of humanity, cultures, and the natural environment.
- Practicing mutual respect for qualities and experiences that are different from our own.
- Understanding that diversity includes not only ways of being but also ways of knowing;
- Recognizing that personal, cultural and institutionalized discrimination creates and sustains privileges for some while creating and sustaining disadvantages for others;
- Building alliances across differences so that we can work together to eradicate all forms of discrimination.
Diversity includes, therefore, knowing how to relate to those qualities and conditions that are different from our own and outside the groups to which we belong, yet are present in other individuals and groups. These include but are not limited to age, ethnicity, class, gender, physical abilities/qualities, race, sexual orientation, as well as religious status, gender expression, educational background, geographical location, income, marital status, parental status, and work experiences. Finally, categories of difference are not always fixed but also can be fluid. Diversity includes respecting an individual’s right to self-identification and recognizing that even though hierarchies based on identity are built into systems, no one culture or identity is intrinsically superior to another.
Identity: the qualities, beliefs, etc., that make a particular person or group different from others. Some ways in which we identify are connected to groups which are socially ascribed such as gender, race, age, class, sexual orientation, ability, nationality and citizenship, etc.
Implicit Bias: Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. These biases, which we all hold and which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or control. The implicit associations we harbor in our subconscious cause us to have feelings and attitudes about and different responses to people based on characteristics such as race, gender, age, and appearance. These associations develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages. In addition to early life experiences, the media and news prograaming are often-cited origins of implicit associations. Implicit biases are malleable, and since they are learned, they can be gradually unlearned through a vareity of debiasing techniques.
Intersectionality: Though theories related to intersectionality have been around since the 19th century, Kimberlé Crenshaw professor of law and an expert on critical race study first coined the term intersectionality in 1989 to describe how social and cultural identities/categories interrelate on concurrent and multiple levels to create interlocking systems of social inequality. Intersectionality is a theory or standpoint that allows us to see and understand the ways in which social categoris of difference like gender, race, age, class etc are woven together. For example, if a person is transmasculine, brown, and working class with no health insurance, they may have a much more difficult time accessing trans*affirming health care than a transmasculine, white, middle class person with health insurance.
Power: One definition of power that is both simple and useful is: “the ability to get what you want.” Power is a relational term. It can only be understood as a relationship between human beings in a specific historical, economic and social setting. It must be exercised to be visible.
It is worth noting here the difference between forms of power that are ‘power-over’ and ‘power-with’. Power-over is power that is used in a discriminatory and oppressive way: It means having power over others and therefore domination and control over others (e.g. through coercion and violence). Power-with is power that is shared with all people in struggles for liberation and equality. In other words, it means using or exercising one’s power to work with others equitably.
Privilege: A special right, advantage, or immunity granted or available only to a particular person or group of people whether they want those privileges or not, and regardless of their stated intent. Privilege is characteristically invisible to people who have it. People in dominant groups often believe that they have earned the privileges that they enjoy or that everyone could have access to these privileges if only they worked to earn them. In fact, privileges are unearned and they are granted to people in the dominant groups whether they want those privileges or not, and regardless of their stated intent. Unlike targets of oppression, people in dominant groups are frequently unaware that they are members of the dominant group due to the privilege of being able to see themselves as persons rather than being constantly regulated to the level of stereotype. Privilege operates on personal, interpersonal, cultural, and institutional levels and gives advantages, favors, and benefits to members of dominant groups at the expense of members of target groups.
Oppression/Target Groups: Oppression is the combination of prejudice and institutional power, which creates a system that discriminates against some groups (often called “target groups”) and benefits other groups (often called “dominant groups”). Examples of these systems are racism, sexism, heterosexism, cis-sexism, ableism, classism, ageism, and anti-Semitism. These systems enable dominant groups to exert control over target groups by limiting their rights, freedom, and access to basic resources such as health care, education, employment, and housing.
Four Levels of Oppression/”isms”:
- Internalized / Personal Oppression: Values, Beliefs, Feelings
- Interpersonal Oppression: Actions, Behaviors, Language
- Institutional and Structural Oppression: Rules, Policies, Procedures
- Cultural Oppression: Beauty, Truth, Right
Oppression Internalized (inferiority and superiority): Internalized inferiority is the process whereby people in the target group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about them are true. Members of target groups exhibit internalized oppression when they alter their attitudes, behaviors, speech, and self-confidence to reflect the stereotypes and norms of the dominant group. Internalized oppression can create low self-esteem, self-doubt, and even self-loathing. It can also be projected outward as fear, criticism, and distrust of members of one’s target group.
Internalized superiority is the process whereby people in the privileged group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about people in a target group are true, which positions people in the privileged group as superior. Members of privileged group often exhibit internalized superiority by assuming they are smarter and more deserving of decision making power, comfort, and authority than people in the associated target group. This is often expressed through perfectly logical explanations that justify and normalize discriminatory behavior.
Race: Someone has said that “race is a pigment of our imagination”. That is a clever way of saying that race is actually an invention. It is a way of arbitrarily dividing humankind into different groups for the purpose of keeping some on top and some at the bottom; some in and some out. Ant its invention has very clear historical roots; namely, colonialism. “Race is an arbitrary socio-biological classification created by Europeans during the time of worldwide colonial expansion, to assign human worth and social status, using themselves as the model of humanity, for the purpose of legitimizing white power and white skin privilege” (Crossroads-Interfaith Ministry for Social Justice).
To acknowledge that race is a historical arbitrary invention does not mean that it can be, thereby, easily dispensed with as a reality in people’s lives. To acknowledge race as an invention of colonialism is not the same as pretending to be color blind or declaring, “I don’t notice people’s race!” For example, it has been demonstrated that health professionals are less likely to prescribe painkillers for people of color who are experiencing the same symptoms as white people. So, even though race is a social construct, when someone doesn’t get the pain medication that they need because of implicit bias, race and racism have real consequences. Our world has been ordered and structured on the basis of skin color and that oppressive ordering and structuring is racism.
Racism: Racism is a system in which one race maintains supremacy over another race through a set of attitudes, behaviors, social structures, and institutional power. Racism is a “system of structured dis-equality where the goods, services, rewards, privileges, and benefits of the society are available to individuals according to their presumed membership in” particular racial groups (Barbara Love, 1994. Understanding Internalized Oppression). A person of any race can have prejudices about people of other races, but only members of the dominant social group can exhibit racism because racism is prejudice plus the institutional power to enforce it.
Stereotype: An exaggerated or distorted belief that attributes characteristics to members of a particular group, simplistically lumping them together and refusing to acknowledge differences among members of the group.
Cultural Competency: Cultural competency is a common, well-intentioned approach to teaching (presumably) privileged people that cultural mastery of traits, beliefs, traditions, etc. of marginalized communities is possible. While it is certainly important to be aware of cultural practices that are outside one’s own lived experiences and world view, this definition and concept is problematic because it harbors unstated assumptions that trainees are necessarily from a privileged cultural group, that patients of a particular background share homogeneous beliefs, that the complex nuances of difference can be “mastered”, and that ethnic similarity between clinician and patient mandates mutual understanding. Most importantly, traditional cultural competency training, like traditional medical training, is externally focused, primarily concerned with mastering the Other, rather than examining the internal cultures, prejudices, fears, or identifications of the Self in relation to that Other.
Narrative Humility/ Narrative Competence: Craig Irvine describes humility as “The sense of humility toward that which we do not know—the face of the Other, the face we cannot know but to which we are responsible.” Narrative humility acknowledges that patients’ stories are not objects that can be mastered, but rather dynamic entities that can be engaged with, while simultaneously remaining open to their ambiguity and contradiction. Narrative humility means engaging in constant self-evaluation and self-critique about issues such as one’s own role in the story, one’s expectations of the story, one’s responsibilities to the story, and one’s identifications with the story. Narrative humility allows clinicians to recognize that each story heard holds elements that are unfamiliar—be they cultural, socioeconomic, sexual, religious, or idiosyncratically personal. Narrative competency, on the other hand, is not an end point—but rather a skill set that is developed through the practice of narrative humility, which needs to be exercised just like a muscle.
MSU Extension Multi-Cultural Awareness Workshop and http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/
Ignite! A Toolkit for Anti-Racist Education: http://antiracist-toolkit.users.ecobytes.net/?page_id=124
Kirwan Institute for the Study or Race and Ethnicity: http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/
Queensborough Community College: http://www.qcc.cuny.edu/Diversity/definition.html
Text adapted from CEDI Resources and References