# This is Nigel - Canadian Patient Safety Institute

Critical thinking and its impact of patient safety Pat Croskerry MD, PhD Patient Safety Officer Course CPSI, Ottawa April 2011 Life is short, opportunities of knowing rare;

our senses are fallacious, our reasonings uncertain; man therefore struggles with perpetual error from the cradle to the coffin. Erasmus Darwin, Zoonomia, 1794 This session is a focus on our most important faculty How we think

Seven Quick Questions Take a piece of paper and write down your answers to each of these 7 questions You have about 10 seconds for each response On a standard Ottawa fire truck, there are

2 drivers up front, one at the rear and three additional fire-fighters. What is the total personnel required for 5 standard trucks? How many turtle doves did my true love send me on the 2nd day of Christmas?

In 2010, the average time required to complete a root cause analysis was 15 hours, how much time should be allowed for the three that are expected next month? A bat and a ball cost \$1.10 in total. The bat costs \$1.00 more than the ball.

How much does the ball cost? If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100 machines to make 100 widgets? In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it

takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake? In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study. Jack is 36 years old. He is not married and is somewhat

introverted. He likes to spend his free time reading science fiction and writing computer programs What is most likely? a. Jack is an engineer b. Jack is a lawyer De Neys & Glumicic, 2008 Answers A. 30

B. 2 C. 46 hours _________________________________ D. The ball costs 5 and the bat \$1.05 E. 5 minutes F. 47 days G. Jack is a lawyer

In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study. Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs What is most likely? a. Jack is an engineer b. Jack is a lawyer

De Neys & Glumicic, 2008 Cognitive Reflective Test

The test distinguishes intuitive from analytical processing It tests the ability to resist first response that comes to mind Of 3428 people tested only 17% got all 3 correct 33% answered all three incorrectly Frederick 2002 (MIT) The only decision we must make in our lives is how to live our lives

L.J.Savage, 1954 How to live our lives means How to make decisions Gigerenzer et al, 2002 What do we know about decision making?

How well do we make decisions?

A few examples More than half of marriages fail

Chances of winning the lottery are 14,000,000:1 Most newspapers carry astrological forecasts All gambling systems are carefully designed to beat you, yet Half the US population believes the universe is 6000 years old Most people think they are above average drivers We become addicted to many known harmful things Nations go to war to settle differences of opinion People universally believe their god is better than other gods

160 million have died in the last century over religious disputes 10 - 30% of children do not have the father they think they have 37% of US believe creationism should be taught instead of evolution Most university professors think their research area is more important Half the US population believes in UFOs 40% of Canadian Mensa believes in UFOs 9 million Americans reach the criterion for morbid obesity More than 6 out of 10 people believe in extra sensory perception

Extra-Sensory Perception? James Randi Educational Foundation First offer of \$1000 for proof of any psychic/paranormal event made in 1964 Now \$1,000,000 (unclaimed)

James Randi Educational Foundation 201 S.E. 12th Street Fort Lauderdale, FL 33316-1815 USA How well do we make decisions? A review of the

(popular) literature What factors adversely affect decision making?

Biases Information gaps Ambient conditions

Context Availability of resources Well-being of decision maker Cognitive loading Fatigue, sleep deprivation Healthcare is not rocket science Its a lot more complicated

How might we think more critically? Critical Thinking Knowledge of how we reason and make decisions To be able to recognize distracting stimuli, propaganda, irrelevance To know and understand cognitive and affective bias

Ability to identify, analyze, and challenge assumptions in arguments Ability to recognize deception, deliberate or otherwise Capability to assess credibility of information Ability to monitor and control own thought processes Ability to imagine and explore alternatives Understanding of how to effectively work through problems Capacity for making effective decisions

We have a new way of looking at decision making It can be applied to all decision making in healthcare Type 1 and Type 2 processes

(dual process theory) Type 1 (intuitive) Cognitive style Cognitive awareness Cost Automaticity

Rate Reliability Errors Effort Predictive power Emotional component Scientific rigour

Heuristic Low Low High Fast Low Usually Low

Low High Low Type 2 (analytical) Systematic High

High Low Slow High Few High High Low

High Neuroanatomical correlates Type 1 processes: ventromedial prefrontal cortex, nucleus accumbens, amygdala, and lateral temporal cortex Type 2 processes: prefrontal cortex, hippocampus

and medial temporal lobe, posterior parietal cortex X4 C2 C3

C1 X4 X3 X2 X1

Type 2 processing requires effort (22 to 34 Hz) PREFRONTAL CORTEX PARIETAL CORTEX

MT V4 Color identification (60 Hz) Type 1 processing

automatic and effortless (35 to 55 Hz) Spatial attention (25 to 45 Hz) A schematic model for how the systems work together

TYPE 1 RECOGNIZED Patient Presentation

Pattern Processor processes Pattern Recognition

Repetition NOT RECOGNIZED TYPE

2 processes Rational override Dysrationalia override

Calibration Diagnosis Type RECOGNIZED

1 Processes Patient Presentation Pattern Processor

Pattern Recognition Repetition NOT RECOGNIZED

Type 2 Processes Executive override T

Dysrationalia override Calibration Diagnosis

RECOGNIZED System 1 Expertise Proficiency

Initial percept or problem Pattern Processor

Competence Advanced Beginner Novice NOT RECOGNIZED

System 2 Calibration Calibra Decision

Toggle Function (Hypothesis Hopping) Type RECOGNIZED 1 Processes

Patient Presentation Pattern Processor Pattern

Recognition Repetition NOT RECOGNIZED Type 2

Processes Executive override T Dysrationalia

override Calibration Diagnosis 6 Main Features of the Model

Toggle function Most errors occur in System 1

Repetitive operations of System 2 >>> 1 System 2 override of System 1 System 1 override of System 2 Cognitive Miser function BMJ Nov 2010 2005

Blink Malcolm Gladwell (2005) We really only trust conscious decision making. But there are moments, particularly in times of stress,

when haste does not make waste, when our snap judgments and first impressions can offer a much better means of making sense of the world. The first task of Blink is to convince you of a simple fact: decisions made very quickly can be every bit as good as decisions made cautiously and deliberately deliberately P 14

2006 Think Michael Legault (2006) The technique by which we make good

decisions and produce good work is a nuanced and interwoven mental process involving bits of emotion, observation, intuition, and critical reasoning. The emotion and intuition are the easy, automatic parts, the observation and critical reasoning skills the more difficult, acquired parts. The essential background to all this is a solid base of knowledge.

P 12 The power of Type 1 processes Swallowing saliva Would you drink a glass

of your own saliva? The emotion of disgust (System 1) overcomes rational input (System 2) How can we improve decision making in healthcare?

You arent thinking critically enough, so be The occasional slap might wake some people up Other factors that may acutely compromise

clinical decision making Fatigue

Illness, dysphoria Sleep deprivation, sleep debt, sleep inertia Production pressures/RACQITO Group think 10 things Dual Process Theory can do for us Provide a universal model for reasoning and decision making that embraces all approaches

Provide a straightforward approach to teaching decision making Explain how experience/practice leads to automatic behavior Explain how impulsive/irrational decision making occurs Explain how impulsivity/irrational decisions can be overridden Show where cognitive and affective bias occurs Explain how fatigue and sleep deprivation cause decision failures Predict cognitive miserly behavior Predict where weaknesses in the decision making process occur

Predict fruitful areas for research How might we think more critically? Critical Thinking

Knowledge of how we reason and make decisions Able to recognize distracting stimuli, propaganda, irrelevance Recognition of eccentric and sociocentric thinking Intellectual humility To know and understand cognitive and affective bias Able to identify, analyze, and challenge assumptions in arguments

Able to recognize deception, deliberate or otherwise Capability to assess credibility of information Ability to monitor and control own thought processes Ability to imagine and explore alternatives Understanding of how to effectively work through problems Capacity for making effective decisions Cognitive thought is the tip of

an enormous iceberg. It is the rule of thumb among cognitive scientists that unconscious thought is 95% of all thought this 95% below the surface of conscious awareness shapes and structures all conscious thought

Lakoff and Johnson, 1999 Robin Hogarth Educating Intuition Select/create decisionmaking environment Improve feedback

Impose circuit breakers Acknowledge emotions Explore connections Accept conflict in choice Make scientific method intuitive

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