Sources of uncertainty in making early diagnosis

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Sources of uncertainty in making early diagnosis

  1. 1. Sources of uncertainty in making early diagnosis <ul><li>Patient </li></ul><ul><li>Doctor </li></ul>
  2. 2. Article by Pat Croskerry <ul><li>The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them </li></ul><ul><li>Cognitive Dispositions to Respond (CDRs) </li></ul><ul><li>cognitive errors, especially those associated with failures in perception, failed heuristics (problem-solving) and biases </li></ul><ul><li>- The major cognitive biases in medicine and a number of strategies for reducing these diagnostic errors (‘‘ cognitive debiasing ’’) </li></ul>
  3. 3. Examples of CDRs that may lead to diagnostic errors <ul><li>Availability error </li></ul><ul><li>Confirmation bias </li></ul><ul><li>Diagnosis momentum </li></ul><ul><li>Gender bias </li></ul><ul><li>Search satisfying </li></ul><ul><li>Sutton’s slip </li></ul>
  4. 4. Article by Richard Horton <ul><li>What’s Wrong With Doctors </li></ul><ul><li>Reviews the book “How Doctors Think” by Jerome Groopman </li></ul><ul><li>“ Often patients have conditions or combinations of conditions that do not easily match the supposed evidence. Sometimes patients have problems that are not easy to study scientifically .” </li></ul><ul><li>Groopman concludes that doctors are “being conditioned to function like a well-programmed computer that operates within a strict binary framework.” </li></ul>
  5. 5. <ul><li>“ Availability error” </li></ul><ul><li>“ Confirmation bias” </li></ul><ul><li>“ Diagnostic momentum” </li></ul><ul><li>“ Commission bias”  </li></ul><ul><li>“ Search satisfying error” </li></ul>
  6. 6. <ul><li>Availability error : </li></ul><ul><li>- Dr makes decision based on recent experience or their specialty </li></ul><ul><li>- recent experience may inflate likelihood of its being diagnosed </li></ul><ul><li>- eg. Woman with abdominal pain went to see a specialist in gastroenterology </li></ul><ul><li> Dr may only think about gut – but her symptoms can be due to anything eg. appendicitis </li></ul>
  7. 7. <ul><li>Search satisfying: </li></ul><ul><li>Dr calls off search for answer once something that satisfies him/her is discovered </li></ul><ul><li>The answer may be wrong – so Dr has given up too soon. </li></ul>
  8. 8. <ul><li>Diagnostic Momentum: </li></ul><ul><li>A thought started as a possibility </li></ul><ul><li>Dr is unable to change his/her mind about a diagnosis although there may be some considerable uncertainty </li></ul><ul><li>The diagnostic label sticks and all other possibilities are excluded </li></ul>
  9. 9. Cognitive Debiasing Strategies to Reduce Diagnostic Error <ul><li>Consider alternatives </li></ul><ul><li>- Encourage routinely asking the question: What else might this be? </li></ul><ul><li>Metacognition </li></ul><ul><li>- reflective approach to problem solving </li></ul>Pat Croskerry
  10. 10. Why are we uncertain of the plausibility of the diagnosis when it is made early on?
  11. 11. <ul><li>Diagnostic errors : higher morbidity than is the case with other types of medical errors </li></ul><ul><li>These errors arise in all contexts: </li></ul><ul><li>emergency medicine </li></ul><ul><li>GP setting </li></ul>
  12. 12. Patient <ul><li>General symptom/common presentation: can be due to any underlying cause </li></ul><ul><li>Eg. Symptom = headache </li></ul><ul><ul><ul><li>Cause = stress, head injury, migraine, dehydration </li></ul></ul></ul><ul><li>With respect to patient = Patient perception of presenting complaint </li></ul>
  13. 13. <ul><li>Uncertainty lies in the fact that different patients have different perceptions of the symptoms </li></ul><ul><li>Eg. Patient comes to Dr with severe back pain. </li></ul><ul><li>What is severe? </li></ul><ul><li>It may be severe to this patient, but mild pain to another patient. </li></ul>
  14. 14. <ul><li>Uncertainty also lies in the fact that there may be other associated symptoms, which are helpful for diagnosis, but patient dismissed them as insignificant, so does not present them to doctor </li></ul>
  15. 15. Doctor <ul><li>Lack of investigation </li></ul><ul><li>Eg. Patient comes to see GP in clinical setting with headache </li></ul><ul><li>- restricted in range of investigation </li></ul><ul><li>Availability of tests like CT scans, lab tests </li></ul>
  16. 16. <ul><li>Symptoms very common – in their experience they may have come across many diseases with that symptom, so they don’t know where to start </li></ul><ul><li>If they are more inclined to one diagnosis, what if it was wrong? It will lead further away from the “truth”. </li></ul>
  17. 17. How to avoid these uncertainties?
  18. 18. Patients… <ul><li>Patients should avoid diagnosing themselves using information from the internet </li></ul><ul><li>They may bring biased information from internet and present those information to the doctor </li></ul>
  19. 19. Doctors… <ul><li>Doctors should work together to figure out patient’s problem, instead of trying to diagnose them themselves </li></ul><ul><li>Ask for advice from more experienced colleagues </li></ul><ul><li>To clear up uncertainties, take patient’s complete history (family, social, medical) </li></ul>
  20. 20. In the wider context… <ul><li>Richard Horton mentioned that doctors should seek ally to correct the cognitive errors </li></ul><ul><li>The ally is the patient </li></ul><ul><li>So doctor should work together with the patient to avoid any uncertainties in making early diagnosis. </li></ul>

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