Cognitive Forcing Strategies Research Articles

Identification of facilitators and barriers to residents' use of a clinical reasoning tool.

While there is some experimental evidence to support the use of cognitive forcing strategies to reduce diagnostic error in residents, the potential usability of such strategies in the clinical setting has not been explored. We sought to test the effect of a clinical reasoning tool on diagnostic accuracy and to obtain feedback on its usability and acceptability. We conducted a randomized behavioral experiment testing the effect of this tool on diagnostic accuracy on written cases among post-graduate 3 (PGY-3) residents at a single internal medical residency program in 2014. Residents completed written clinical cases in a proctored setting with and without prompts to use the tool. The tool encouraged reflection on concordant and discordant aspects of each case. We used random effects regression to assess the effect of the tool on diagnostic accuracy of the independent case sets, controlling for case complexity. We then conducted audiotaped structured focus group debriefing sessions and reviewed the tapes for facilitators and barriers to use of the tool. Of 51 eligible PGY-3 residents, 34 (67%) participated in the study. The average diagnostic accuracy increased from 52% to 60% with the tool, a difference that just met the test for statistical significance in adjusted analyses (p=0.05). Residents reported that the tool was generally acceptable and understandable but did not recognize its utility for use with simple cases, suggesting the presence of overconfidence bias. A clinical reasoning tool improved residents' diagnostic accuracy on written cases. Overconfidence bias is a potential barrier to its use in the clinical setting.

SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care

SOAP to SOAP-V: A New Paradigm for Teaching Students High Value Care

BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors

A short review was carried out to see if teaching cognitive forcing strategies reduces cognitive error in the practice of emergency medicine. Two relevant papers were found using the described...

Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review

BackgroundDiagnostic error incurs enormous human and economic costs. The dual-process model reasoning provides a framework for understanding the diagnostic process and attributes certain errors to faulty cognitive shortcuts (heuristics). The...

The effect of cognitive debiasing training among family medicine residents

Debiasing education has been recommended for physicians in training. We report on the efficacy of a workshop designed to aid family medicine residents recognize and respond to their risk of misdiagnosis due to cognitive biases during patient care. Residents participated in a debiasing workshop in which they were taught to recognize and respond to cognitive biases likely to contribute to misdiagnosis. Metacognition was introduced and cognitive forcing strategies were demonstrated and practiced. While precepting clinic visits, attendings evaluated residents in the following areas: 1) diagnostic concordance between resident and attending, 2) ability of the resident to perceive their risk of cognitive bias, 3) the quality of the resident's plan to mitigate this risk, and 4) the presence of an unrecognized cognitive bias. Pre and post workshop data were compared. Preceptor concurrence with the residents' diagnoses was unchanged - 74% (63 of 85) vs. 78% (45 of 58, p=0.64). Residents' ability to recognize their risk of cognitive bias was unchanged - 51% (43 of 85) vs. 57% (33 of 58, p=0.46). Residents' formulation of an acceptable plan to mitigate the effect of cognitive bias increased from 84% (36 of 43) to 100% (33 of 33, p=0.02). Preceptors' perception of an unrecognized cognitive bias in the residents' presentation was unchanged - 12% (10 of 85) vs. 9% (5 of 58, p=0.55). A debiasing workshop for family medicine residents demonstrated improvement in one of four studied outcomes.

Ineffectiveness of cognitive forcing strategies to reduce biases in diagnostic reasoning: a controlled trial

Cognitive forcing strategies (CFS) may reduce error arising from cognitive biases. This is the first experimental test to determine the effect of CFS training in medical students. Students were allocated to CFS training or control during a 4-week emergency medicine rotation (n = 191). At the end of the rotation examination, students were tested using computer-based cases. Application of CFS could enable reduction of diagnostic error, as evidenced by identifying multiple correct diagnoses for the two cases prone to search satisficing bias (SSB) and uncommon diagnoses for the two cases prone to availability bias (AB). Two "false positive" cases were included to test for possible "oversearching." There were 145 students in the intervention and 46 in the control group. For the SSB cases, 52% of students with CFS training and 48% in the control group initiated a search for the second diagnosis (χ2 = 0.13, df = 1, p = 0.91). More than half (54%) correctly identified the second diagnosis in the CFS group, and 48% identified it in the control group. The difference was not significant (χ2 = 2.25, df = 1, p = 0.13). For the second diagnosis in the false positive cases, 64% of the CFS group and 77% of the control group incorrectly identified it. There were no significant differences between groups (χ2 = 2.38, df = 1, p = 0.12). In the AB cases, only 45% in each group identified the uncommon correct diagnosis (χ2 = 0.001, df = 1, p = 0.98). The educational interventions suggested by experts in clinical reasoning and employed in our study to teach CFS failed to show any reduction in diagnostic error by novices.

Why Do Doctors Make Mistakes? A Study of the Role of Salient Distracting Clinical Features

Diagnostic errors have been attributed to faulty reasoning and cognitive biases, but minimizing errors requires understanding the mechanisms underlying biases. The authors investigated whether salient distracting features (SDFs)-case findings that tend to grab physicians' attention because they are strongly associated with a particular disease, but are indeed unrelated to the problem-misdirect diagnostic reasoning, causing errors. In a 2012 study conducted at Erasmus Medical Centre, Rotterdam, 72 internal medicine residents diagnosed 12 clinical cases (6 simple, 6 complex) in three different formats: without a SDF, with a SDF in the beginning, and with a SDF at the end. In a within-subjects design, each participant solved 2 simple cases and 2 complex cases in each format. Proportions of correct diagnoses in each case type were compared by performing repeated-measures analysis of variance (ANOVA). There was a significant main effect of SDFs and a significant interaction effect between SDFs and case complexity. The presence of SDFs in the beginning of complex cases caused errors decreasing the proportion of correct diagnoses in comparison both with cases without SDFs (0.18, 95% CI, 0.13-0.23 versus 0.43, 95% CI, 0.35-0.51; P < .001) or with SDFs at the end (0.18, 95% CI, 0.13-0.23 versus 0.36, 95% CI, 0.29-0.43; P < .001). SDFs did not affect performance when presented near the end of cases. SDFs early in a case are apparently an important source of diagnostic errors. Physicians should be aware of the need to overcome their influence.

Teaching and learning clinical decision-making for person-centered medicine: recommendations from a systematic review of the literature

Rationale, aims and objectives: Clinical decision-making (CDM) has been studied from diverse perspectives, including diagnostic cognition, clinical error and probabilistic modelling of patient management under uncertainty. This paper aims to establish the current knowledge base for CDM by systematic review, in order to produce recommendations for clinicians and clinical teachers. Method: Biomedical, social science and education databases were searched. All English-language articles concerning CDM in medical education, from peer-reviewed academic journals, were included. Meeting abstracts were hand searched for relevance. 236 citation abstracts were kept for consideration, then themed for ease of analysis. Current thinking was reviewed and discussed, and key recommendations for teaching CDM were made for clinicians. Results: The hypothetico-deductive cognitive method is criticised, as experts use little hypothesis testing. Clinical expertise is associated with better content-specific memory, consisting of encapsulated biomedical and clinical knowledge as goal-directed knowledge-structures (illness scripts). These are rich, accessible and activated intuitively (pattern recognition). Decision theory and Bayes’ theorem provide a mathematical rule for rationalising a hypothesis and decision analysis updates this for complex decisions. Clinicians should appreciate the nature and impact of cognitive errors on CDM and use cognitive forcing strategies to lessen them. Conclusion: Analytical and non-analytical (intuitive) models of CDM are not mutually exclusive and dual-process or additive models of CDM account for this. Key recommendations for clinical teaching include development of knowledge encapsulations as individual constructs, combined learning of analytical and intuitive elements and reducing cognitive error by metacognition, forcing strategies and constructive feedback.

(A104) Simulation in Disaster and Emergency Medicine

SimulationAn activity or situation that produces conditions which are not real, but have the appearance of being real, used especially for testing something. Longman Dictionary of Contemporary English. Simulation has evolved over the centuries but has not been applied to medicine until the 20th century with the introduction of virtual reality and computers. Prior to the 20th century simulation took the forms of physical models and cadavers. With the introduction of flight simulation there was an effort to move similar approaches into medicine. This was pushed by the demands of minimally invasive surgery and the introduction of robotics in surgery. In the 21st century in addition to cognitive task analysis tools we are beginning to see the migration of advanced intelligence tools to simulation. We are just at the beginning of how we will use adversarial reasoning in the medical environment and in high risk time constrained situations like Emergency Medicine. The practitioner of emergency medicine is at high risk for errors because of multiple factors including high decision density, high levels of diagnostic uncertainty, high patient acuity, and frequent distractions. Some authors have suggested that instructing physicians in “cognitive forcing strategies” or “metacognition” will help reduce the amount of cognitive error in medical practice. It has been said ‘‘[There is an] ethical obligation to make all efforts to expose health professionals to clinical challenges that can be reasonably well simulated prior to allowing them to encounter and be responsible for similar real-life challenges.’' TYPES OF SIMULATION • Verbal • Tactile • Visual • Situational • Environmental TYPES OF SIMULATION TRAINING • Standardized patients (role play) • Basic models (partial task trainers) • Simple level • Higher level • Mannequins • Low fidelity • High fidelity • Virtual patients • Screen-based; computer-based • COMBINATIONS • Augmented sp encounters with technology • Crises management HUMAN PATIENT SIMULATION • Realistic • Suitable for all levels • Safe • Wide variety of training programs • Expensive ADVANTAGES OF SIMULATION • Patients are never at risk • Serious but infrequent events, in predictable times and places • Errors can be allowed to occur, and play-out • Rehearsal, repetition, mastery • Crisis management simulation, planning • Reduces institutional liability • Increases operational confidence • Produces rapid results • Allows team training • Increases institutional prestige The use of high fidelity simulations to train multidisciplinary teams in critical environments is well established.

The Effectiveness of Cognitive Forcing Strategies to Decrease Diagnostic Error: An Exploratory Study

Background: Cognitive forcing strategies, a form of metacognition, have been advocated as a strategy to prevent diagnostic error. Increasingly, curricula are being implemented in medical training to address this error. Yet there is no experimental evidence that these curricula are effective. Description: This was an exploratory, prospective study using consecutive enrollment of 56 senior medical students during their emergency medicine rotation. Students received interactive, standardized cognitive forcing strategy training. Evaluation: Using a cross-over design to assess transfer between similar (to instructional cases) and novel diagnostic cases, students were evaluated on 6 test cases. Forty-seven students were immediately tested and 9 were tested 2 weeks later. Data were analyzed using descriptive statistics and a McNemar chi-square test. Conclusions: This is the first study to explore the impact of cognitive forcing strategy training on diagnostic error. Our preliminary findings suggest that application and retention is poor. Further large studies are required to determine if transfer across diagnostic formats occurs.

Profiles in Patient Safety: Confirmation Bias in Emergency Medicine

Confirmation bias is a pitfall in emergency care and may lead to inaccurate diagnoses and inappropriate treatments and care plans. Because of the increasing severity and volume of emergency care, emergency physicians often must rely on heuristics, such as rule-out protocols, as a guide to diagnosing and treating patients. The use of heuristics or protocols can be potentially misleading if the initial diagnostic impression is incorrect. To minimize cognitive dissonance, clinicians may accentuate confirmatory data and ignore nonconfirmatory data. Clinicians should recognize confirmation bias as a potential pitfall in medical decision making in the emergency department. Reliance on the scientific method, Bayesian reasoning, metacognition, and cognitive forcing strategies may serve to improve diagnostic accuracy and improve patient care.

Medical error during residency: To tell or not to tell

Medical error during residency: To tell or not to tell

Cognitive forcing strategies in clinical decisionmaking

Cognitive errors underlie most diagnostic errors that are made in the course of clinical decisionmaking in the emergency department. These errors are universal and are prevalent in the special milieu of the ED. Their properties appear to be distinct from those associated with the performance of procedures. They are often costly, but, importantly for both the patient and the physician, they are also highly preventable. Recent developments in education theory provide a means for minimizing and avoiding diagnostic error. Through the process of metacognition, clinicians can develop cognitive forcing strategies to abort such latent errors. Three levels of cognitive forcing strategies are described: universal, generic, and specific. Specific cognitive forcing strategies provide a formal cognitive debiasing approach to deal with what have previously been described as pitfalls in clinical reasoning. This metacognitive approach can be taught to practicing clinicians and to those in training to inoculate them against making diagnostic errors. The adoption of this method provides a systematic approach to cognitive root-cause analysis in the avoidance of adverse outcomes associated with delayed or missed diagnoses and with the clinical management of specific cases. [Ann Emerg Med. 2003;41:110-120.]