There are traps we step in without our daily lives that are predictable. In medicine, this leads to unexpected outcomes. This is a lecture I present to national audiences to help people understand the thinking process and optimize it.

1. “Thinking That’s Stinking”
John Bielinski MS PAC

2. “Fiduciary”

3. How Big is the Problem?
How big is the problem?
1999 “To Err is Human”
44K-98K Deaths
Really?

4. Case
Study:
Baby Nathan

5. • PA-Moved from orthopedics to EM
• Little experience with pediatrics
• Increased work pressure to see kids
• “Come see this kid, he has a cold, and the parents
are young”
• Fever of 101.8
• Doctor: “Send them home. Tylenol PRN”
• Dx. “Viral Syndrome”
• The child is 3 weeks old
• Next day: Child becomes septic and dies

7. Why do Errors Happen?
No Fault Systemic
Cognitive

8. True Lack of
Information
“First
Visit
Zebra”
Deliberate
Misrepresentation/Somatizati
on
Malingering
AMA
(Informed Refusal)
Silent
Presentation
of Disease
No Fault

9. Error
Producing
Conditions
Radiology/
Lab Error
Lack of
Feedback/
Follow up
Unavailability of Services
“RACQITO”
Low “Signal to
Noise” Ratio

10. “RACQITO”
Resource Availability
Continuous Quality
Improvement Tradeoff
Resource Availability Continuous Quality
Improvement Trade Off

11. Emotion is
inseparable
from
Cognition

12. Dysfunctional
Emotions?
• H = Hungry
• A = Angry
• L = Lonely
• T = Tired

14. Attribution
Error
Search
Satisfying
Anchoring
Triage Cueing
Vertical Line
Thinking/Diagnostic
Momentum
Premature
Closure
Availability
Posterior
Probability
Confirmation
Bias
I:E Ratio
Mismatch
Framing

15. Attribution Error
1
Tendency to place an
undue emphasis on
internal characteristics to
explain someone else's
behavior in a given
situation

16. SearchSatisfying
2
The tendency to stop searching for a
secondary on contributing problem after a
problem is identified .

17. “RACQITO”
Resource Availability
Continuous Quality
Improvement Tradeoff
Search Satisfying
Start asking, is this the BEST plan? 
3

18. Anchoring & Triage Cueing
3
The tendency to rely too heavily on one trait
or piece of information when making
decisions.

19. Posterior
Probability4
The tendency to rely too heavily on past
events to influence current decisions.

20. 5
The tendency to allow
past decisions to guide
future decisions without
challenge.

21. 6
Drawing different
conclusions from the
same information,
depending on how (or by
whom) that information
is presented.

22. Premature Closure
7 The tendency to end a decision-making process
early, before due diligence complete.

23. Availability
8
The tendency to overestimate the likelihood of
events with greater "availability" in memory, which
can be influenced by how recent the memories are
or how unusual or emotionally charged they may be.

24. Availability
Proximity or
Intensity

25. Confirmation
Bias
9
The tendency to search for, interpret, focus on
and remember information in a way that
confirms one's preconceptions.

26. Reasoning
Confirmation
Bias
vs. Rationalizing
We are ONLY looking at facts that CONFIRM the
illogical decision we already made!

27. Intelligence to Ego Ratio
11

28. Peds CV ID GYN Ortho
Know Your “Horizontal
Lines”
12

29. “Thinking
that’s
Stinking”
to Avoid:

30. Avoid “Bell Jar Thinking”

31. • PQ
– Heart attack today  differently?
• SQ
– Speak to God quarterly  differently?
• IQ
– ½ life career 2 years  differently?
• EQ
– Everything you said about another they could hear
you  differently?

32. “I will practice
meta-cognition”

33. “I will never
assign more
then 90%
certainty”

35. “I will mistrust
strong emotions
& avoid value
judgments”

36. “I will mistrust
strong emotions
& avoid value
judgments”

37. “I will decrease
reliance on
memory”

38. “I will develop
and nurture a
system of
accountability
and feedback”

39. “I will keep
my cup
10% Empty”

41. Back to
Nathan and our
case study

42. • PA-Moved from orthopedics to EM
• Little experience with pediatrics
• Increase work pressure to see kids
• “Come see this kids, he has a cold, and the parents
are young”
• Fever of 101.8
• Doctor: “send them home. Tylenol PRN”
• The child is 3 weeks old
• Dx. “Viral Syndrome”
• Next day: Child becomes septic and dies.

43. PA-Moved from orthopedics to EM,
Little experience with pediatrics

44. Increase work
Pressure to see kids
Systemic

45. “Come see this kids, he has a cold, and the
parents are young”

46. Framing
“Comeseethiskids,hehasacold,
andtheparentsareyoung”

47. “Fiduciary”

48. • Art of Critical Decision Making

49. Thank You
NCAPA
See You Next Summer!