Cognitive Biases and Medicolegal Risk in Psychiatry
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1) The document discusses cognitive biases and medicolegal risk in psychiatry. It outlines how rushing judgments and only considering limited present information can lead to errors and bias. 2) It describes the case of LC, where failing to consider his full history of unpredictable behavior and drug use, and overly relying on his stated assurances, led to him being discharged without certification and later harming himself. 3) The author argues that psychiatrists need to broaden their perspectives, slow down their decision making, and consider a patient's full context including history, current state, and anticipated futures to make optimal judgments and reduce legal risk.
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Cognitive Biases and Medicolegal Risk in Psychiatry
- 1. Cognitive Biases and Medicolegal Risk in Psychiatry A/Prof Andrew Carroll Consultant Forensic Psychiatrist ourcuriousminds.com
- 2. 1 4 3 2 Legal frameworks Outline The dangerous lure of fast cross-sectional judgements The Case of LC The need to re-claim time for slower, broader judgements
- 4. LEGAL FRAMEWORKS Provide ‘guard rails’ on the road: guidance as to minimum standards Help ensure DEFENSIBLE and ethical practice DO ourcuriousminds.com
- 5. LEGAL FRAMEWORK: Lay down prescriptive ‘tram-tracks’ Encourage DEFENSIVE practice Dictate details of care DO NOT ourcuriousminds.com
- 6. e.g. Civil Liability Act 2003 (Qld) S13 (all legislation very similar across Australia & UK) “(a) the risk was foreseeable (that is, it is a risk of which the person knew or ought reasonably to have known); and (b) the risk was not insignificant; and (c) in the circumstances, a reasonable person in the person's position would have taken those precautions.” ourcuriousminds.com Professionals (including Psychiatrists) must take appropriate precautions if:
- 7. Reasonable psychiatric practice requires us to: • engage in good enough judgements to determine whether we should take a particular precaution ourcuriousminds.com
- 8. 1 4 3 2 The dangerous lure of fast cross-sectional judgements
- 9. Daniel Kahneman, 2011 A remarkable aspect of your mental life is that you are rarely stumped. The human tendency to rush our judgements and decisions… Kahneman, D. (2011). Thinking, fast and slow. ourcuriousminds.com
- 11. What you see… We are prone to pay excessive attention to things that come to mind easily… …Is All There Is …and we are prone to ignore other things that are also relevant “What You See Is All There Is”: the basis of bias Kahneman
- 12. POTENTIAL SOURCES OF ERROR & BIAS ‘What I can remember is more likely’ ‘What I have experienced is more likely’ ‘What I can easily imagine is more likely’ ‘What I want is more likely’ ‘What I expect is more likely’ Base-rate data Contextual influences Relevant factors (often ignored) related to the likelihood of possible harms Irrelevant but readily AVAILABLE feelings and thoughts that can influence estimates of likelihood ourcuriousminds.com
- 13. POTENTIAL SOURCES OF ERROR & BIAS ‘What I can remember is more likely’ ‘What I have experienced is more likely’ ‘What I can easily imagine is more likely’ ‘What I want is more likely’ ‘What I expect is more likely’ Base-rate data Contextual influences Relevant factors (often ignored) related to the likelihood of possible harms Irrelevant but readily AVAILABLE feelings and thoughts that can influence estimates of likelihood ourcuriousminds.com
- 14. CONTEXT PATIENT “THE HERE AND NOW”: a necessary foundation but NOT SUFFICIENT for optimal decision-making ourcuriousminds.com The “FAST” psychiatric evaluation FAST THINKIN
- 15. CONTEXT PATIENT THE CROSS-SECTIONAL MENTAL STATE AND PRESENTING ISSUES: • A SNAPSHOT IN TIME • GIVES US ONLY A VERY LIMITED INFORMATION SET ourcuriousminds.com The “FAST” psychiatric evaluation FAST THINKIN
- 16. CONTEXT PATIENT THE CROSS-SECTIONAL MENTAL STATE AND PRESENTING ISSUES: • A SNAPSHOT IN TIME • GIVES US ONLY A VERY LIMITED INFORMATION SET ourcuriousminds.com fail to consider other, potentially very relevant and potent risk factors that are not evident cross- sectionally The “FAST” psychiatric evaluation FAST THINKIN
- 17. CONTEXT PATIENT MANY cases that result in litigation have occurred because of a failure to adopt a sufficiently BROAD perspective ourcuriousminds.com
- 18. WE NEED TO EXPAND OUR THINKING…
- 19. What you see… …Is NOT All There Is !
- 20. CONTEXT PATIENT HISTORY NOW ANTICIPATED FUTURES ourcuriousminds.com
- 21. 1 4 3 2 The Case of LC
- 22. Case of LC (ACT) [2017] ACTSC 324 Man in early 20’s Academic decline from mid-teens Recent years: THC, opiate, stimulant abuse ourcuriousminds.com
- 23. 10 September 2007 LC “really agitated, really upset and crying…kept saying that he was a bad person and of no use” CAT Assessment: paranoid ideation reported visual and auditory hallucinations saying that they wanted him to die raised possibility of a drug induced first episode of psychosis discharged home with his mother to support him ourcuriousminds.com
- 24. 11 September 2007 CAT Team visit ~ 9 pm Last 3 to 4 months unusual beliefs including: People were following him and talking about him Mother was not his real mother Friends had been lacing his drinks with “ice” “Sammy” had given him AIDS… He denied any thoughts of self-harm He accepted medication ourcuriousminds.com
- 25. 12 September 2007 ~4 am LC very agitated “very loud” voices talking to him in his head Medication had not helped to sleep Used large knife to slash both wrists and his neck. Mum rang 000 LC said “don’t call” and fled Police found him on roof of neighbouring house - trying to jump off Taken to hospital ourcuriousminds.com
- 26. 12 September 2007 morning at Canberra Hospital Medically cleared Mental health clinician assessment: Informed by ED staff that LC cooperative and compliant Noted that “currently extremely delusional” BUT “reports that he will not try to kill himself anymore and he stated that he wants to make peace with everyone” LC stated that willing to wait to be reviewed Not certified ourcuriousminds.com
- 27. Early afternoon When briefly left alone, LC absconded from the hospital, chased by a security guard. Jumped from multi-storey car park complex fractures to both legs. Notes later suggested was reacting to hallucinatory symptoms ourcuriousminds.com
- 28. Justice Burns of SUPREME COURT of the AUSTRALIAN CAPITAL TERRITORY “…beyond any doubt that the plaintiff had, before he attended the hospital on 12 September 2007, behaved unpredictably in engaging in self-harm. I use the term “unpredictably”, because his actions were contrary to the assurances that he gave to doctors and mental health workers on 10 and 11 September 2007, that he would not harm himself…” ourcuriousminds.com
- 29. Justice Burns of SUPREME COURT of the AUSTRALIAN CAPITAL TERRITORY “…beyond any doubt that the plaintiff had, before he attended the hospital on 12 September 2007, behaved unpredictably in engaging in self-harm. I use the term “unpredictably”, because his actions were contrary to the assurances that he gave to doctors and mental health workers on 10 and 11 September 2007, that he would not harm himself…” ourcuriousminds.com Emphasises importance of the longitudinal history of unpredictable behaviour: a less overt but nonetheless very relevant and potent risk factor
- 30. Justice Burns of SUPREME COURT of the AUSTRALIAN CAPITAL TERRITORY “… does not accord with common sense to suggest that a medical practitioner conducting an assessment of the plaintiff …would place significance on assurances by a patient such as the plaintiff that he would not engage in further acts of self- harm…” ourcuriousminds.com
- 31. Justice Burns of SUPREME COURT of the AUSTRALIAN CAPITAL TERRITORY “… does not accord with common sense to suggest that a medical practitioner conducting an assessment of the plaintiff …would place significance on assurances by a patient such as the plaintiff that he would not engage in further acts of self- harm…” ourcuriousminds.com Emphasises importance of not entirely relying on “what you see” (the “assurance”)
- 33. CONTEXT PATIENT HISTORY NOW ANTICIPATED FUTURES ourcuriousminds.com
- 34. CONTEXT PATIENT HISTORY NOW ANTICIPATED FUTURES ourcuriousminds.com CLINICIAN IGNORED THIS
- 35. CONTEXT PATIENT HISTORY NOW ANTICIPATED FUTURES ourcuriousminds.com CLINICIAN IGNORED THIS PUT TOO MUCH WEIGHT ON THIS
- 36. CONTEXT PATIENT HISTORY NOW ANTICIPATED FUTURES ourcuriousminds.com CLINICIAN IGNORED THIS PUT TOO MUCH WEIGHT ON THIS AND SO COULD NOT PROPERLY ASSESS FOR THIS
- 37. 1 4 3 2 The need to re-claim time for slower, broader judgements
- 38. Hang on, there’s a decision to be made here…let’s just think this through a moment... THE POWER OF THE PAUSE ourcuriousminds.com
- 39. At least consider the opposite of what ‘fast thinking’ tells you Seek to dis-confirm (rather than confirm) your initial ideas Systematically consider all realistic options even when majority/intuition is clearly in favour of one over the others Consciously seize control of your ‘mental spotlight’ and broaden its sweep ourcuriousminds.com
- 40. Be prepared to : - change your mind - be the domino that does not fall Disempowered practitioners Derailed decision-making GROUPTHINK often pressures us into fast, cross-sectional judgements ourcuriousminds.com
- 41. Take time with phenomenology • Psychiatric training rich knowledge of phenomenology : a toolkit for understanding the inner world of patients • Making use of that training encourages others to think broadly ourcuriousminds.com
- 42. Don’t collude with ‘fast’ but dumbed down approaches! ourcuriousminds.com
- 44. For more on how Psychiatrists can enhance their judgement skills and reduce their exposure to medicolegal risk: ‘Beyond the Tickbox’ : an online course developed by forensic psychiatrists and medical negligence lawyers: bit.ly/tickboxcourse ourcuriousminds.com