Thinking about thinking errors or why do I keep f**king up?
Thinking about thinking errors or Why do I keep messing up? By Dr Paul Driscoll GP Trainer Felixstowe Case 1
16 year old girl vomiting and amenorrhoea, headache, 3 year history sinusitis. Patient denied sexual activity, seen several times over 3 months by different GPs and OOH service. Patient treated as sinusitis. Home preg test proved positive. Normal delivery. Post-natal depression. Claim against GP arguing had she known preg she would have req termination. MDDUS expert
opinion, suggest weak defence. Settlement agreed What errors could have occurred here? How do we learn to evaluate patients? Hypothetico deductive reasoning (Bayesian analysis) Discrete linear process
Patient history Physical exam Tests Analyse results BUT .. Sir Karl Popper, Swans, and the General Practitioner Ref: BMJ 5.11.2011 vol 343 pg955/56 Patient 48 year old lady, previous Ca breast, back pain, school teacher, lifting heavy box from
car. Seen several times by several doctors. Simple analgesia advice, physiotherapy, stronger analgesia, pain worsened. MRI private and A+E Diagnosis: Cancer Similar case described in BMJ Popper if you suppose all swans are white, you will not find any swans other than white swans. You should in fact be searching for black swans. Article described confirmation bias But Its not what we do First visual impression (in waiting room)
Hand shake Review notes Previous experience etc Heuristics Frequency of medical errors Leape et Al 1991 1.00% 3.00%
96.00% All events Adverse Outcomes (3.7) Negligence
2 of 3 claims from patients with no adverse outcome not due to negligence Only 3% of patients who suffered filed a lawsuit Localio 1991 International analysis is consistently showing only 2-3% of patients filed some sort of claim Andrews et al 1997 Studdert et al 2000 - Davis 2002 Majority of claims are made by patients who have not experienced medical negligence
Studdert et al 2000 ACC Review 2003 Now for the good news! RISK IS RELATED TO COMMUNICATION This is what we have been teaching as trainers for years Medical Errors - Why do they matter? 1. Harm to patients
2. Cost to the system 3. Cost to the clinician Complaints process harms Doctors health, says study By Stephanie Jones-Berry GMC investigations and complaints procedures have a serious impact on doctors health and affect clinical care, research suggests. The BMA said proper support must be given to Doctors under going investigations after the study found those affected experience mental health problems. Doctors subject to investigation experience high rates of depression,
anxiety and suicidal thoughts, says the study in the online journal BMJ Open. BMA council chair Mark Porter said the research exposed wider health implications for Doctors facing complaints. There are growing concerns over how the complaints process is affecting Doctors, with sometimes tragic results, he said. Doctors facing complaints are more likely to have poorer health and well-being, including suffering from insomnia or relationship problems. A Doctors first priority is always to their patient, but we must not ignore the impact that having a complaint made against them, and the subsequent questioning of their professionalism, can have. Cont.
The study found four out of five of the 7,926 Doctors surveyed reported changing the way they treat patients as a result of complaints against themselves or colleagues. Dr Porter said rising workloads already meant more stress for Doctors and emphasised the importance of proper support for Doctors facing complaints procedures. He added that, although concerns should be investigated properly, the process must be fair and offer adequate protection to ensure the system does not cause harm to Doctors or patients. Lead author of the study by Imperial College London, Tom Bourne, said the research showed the regulatory system had unintended consequences that were seriously damaging to Doctors. He said: The vast majority of Doctors referred to the GMC are found to have
no case to answer, yet many Doctors being investigated show high levels of psychological morbidity and we know this impacts how they treat patients. bma.org.uk/doctorswellbeing Doctor Suicides GMC study 2005-13 28 doctors died by suicide during fitness to practise procedure GMC response.
develop emotional resilience!!!!!!! Addressing thinking errors Thinking Errors Samuel Gorovitz and Alexander McIntyre Nature of Human Fallibility
Toward a theory of medical fallibility The Journal of Medicine and Philosophy 1976 Vol 1 No 1 1. Ignorance 2. Ineptitude A study of 100 medical errors showed only 4% were due to medical ignorance. Types of Ineptitude (thinking errors) Anchoring bias Availability bias Confirmation bias
Diagnosis momentum Overconfidence bias Premature closure Search satisfying bias Anchoring bias Locking on to a diagnosis too early and failing to adjust to new information.
Jumping to conclusions. Example: Patient presents with chest epigastric pain, smoker, drinker, previous dyspepsia. In fact patient turns out to be having an MI. Availability Bias
Last bad experience. Thinking that a similar recent presentation is happening in the present situation. Example: Patient presents with lower abdominal pain and altered bowel habits. Clinician has recently seen many other patients with diverticular disease and
makes that diagnosis. Confirmation Bias Karl Poppers White Swans Looking for evidence to support a preconceived opinion, rather than looking for information to prove oneself wrong.
Example: Patient seen with upper abdo pain, heavy drinker, some weight loss, blood test normal. Clinical diagnosis of dyspepsia. Weight loss continues, build up drinks and PPI, ultrasound scan normal. Eventual diagnosis CA Pancreas. Diagnosis Momentum Accepting previous diagnosis without sufficient scepticism.
Example: Patient seen with headache and facial pain. Initial diagnosis of sinusitis. Seen several Doctors over several weeks. Eventual diagnosis brain tumour. Overconfidence Bias Over-reliance on ones own ability, intuition and judgement.
Example: Child with temperature and rash. Feeling unwell. Conjunctivitis. Mum concerned re measles but dismissed, in fact patient was un-vaccinated, traveller family, and it was measles. Premature Closure Similar to confirmation bias but more
jumping to conclusion. Example: 65 year old lady with anxiety and depression. Chest pain, frequent attender, put down as anxiety, in fact MI. Search Satisfying Bias The eureka moment that stops all further thought.
Example: 45 year old lady, abdomen pain and bloating. Recent work stress. Blood tests: FBC ESR Coeliac antibodies. Normal diagnosis of IBS, in fact CA Ovary. Case Study 2 How many thinking errors can you identify? Consider another case. An overweight lady on
the contraceptive pill presents to her doctor complaining of pain in her left calf. GP A is unsure of the diagnosis but appears to consider and eliminate the possibility of a deep vein thrombosis (DVT). The patient then consults GP B at the same practice 7 days later and now also complains of chest pain on deep inspiration. GP B treats the patient with a nonsteroidal drug and sends her on her way. cont. Cont.
Later the same evening an out-of-hours doctor suspects a pulmonary embolism and admits her to hospital. The diagnosis is confirmed and fortunately the lady is treated successfully and makes a full recovery. An allegation of medical negligence is subsequently made against both GPs, claiming that they failed to note the gravity of the situation and that such a failure was not reasonable. What thinking errors were at play here?
Solutions specific Think about ways of preventing each specific thinking error. (Group Work) Solutions general Thinking time What's the worst it could be? What else could it be? What doesnt fit?
Is it possible, more than one diagnosis? Thank you
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