Mistakes 2

“Last time we talked, Curmudge, you promised to provide more countermeasures against making mistakes.”

“I’ll try, Jaded Julie, but sometimes the best defense is knowing the conditions under which mistakes can occur. Here’s an example from Hallinan’s book (1). It takes 10 years and a lot of practice to become a world-class expert, as in med school—internship—residency—fellowship, etc. Having a big library of the mind allows experts to quickly recognize patterns that others don’t; this allows people to develop shortcuts from their cognitive maps. However, overconfidence tends to be higher with tasks of great difficulty. In addition, information overload leads us to believe that we know more than we actually do.”

“And the countermeasures are…”

“Feedback is very helpful. The weather forecaster learns today whether the forecast he made yesterday was correct. Physicians get feedback during residency, but it’s rare when they are practicing independently (radiology and pathology are exceptions). M & M (morbidity and mortality) conferences are valuable but infrequent. Doctors need to be their own devil’s advocate and try to envision what might go wrong, especially when performing diagnoses. Graber and others (2, 3) call this ‘metacognition,’ the ability to monitor and understand one’s own thought processes.”

“C’mon, Curmudge, docs don’t have time to sit around second-guessing themselves.”

“Nevertheless, they should know that the odds of a wrong diagnosis are closer to 10% than 1%, and they should be aware of these countermeasures:
Learn (and be wary of) the inherent biases that can lead to errors.
‘Once you’ve come up with a working hypothesis, examine it carefully and consciously. Consider the opposite, rethink your key assumptions, and think about diagnoses that you can’t afford to miss.’”

“That sounds like good advice for a difficult diagnosis, but it’s probably more than is needed for a kid with a runny nose. But why should a physician go through all this ‘metacognition’ mental gymnastics when there is so much information available at one’s fingertips like we discussed back on August 6, 2009?”

“The more that I read about clinical decision support systems like ‘Isabel,’ the better they sound. But decisions on the use of these tools are in the realm of the clinician, not me. The same can be said about checklists; these are discussed at length in books (see Amazon.com) and other writings by Atul Gawande, Peter Pronovost, and others. Their use in reducing errors is well documented.”

“As I understand it, Curmudge, checklists pick up some of your brain’s memory load and free it up to concentrate on really tough problems.”

“I have a friend—older than I am—who says that his memory is perfect because he writes everything down. So you see that notes and checklists are valuable at all walks of life, especially for those of us subject to ‘senior moments.’”

“And you certainly have those, Curmudge. Are there other ways you’d recommend for minimizing mistakes?”

“Sure, Julie. Think ahead and prepare for bad things that might happen. Losing power in both airplane engines certainly qualifies as a ‘bad thing,’ and Captain Sullenberger attributed his survival to standardized work, crew resource management, and checklists.”

“So have you had any personal experiences like that, Curmudge?”

“Not nearly that serious. Many years ago my wife lost her cash and credit cards to a group of child pickpockets in Paris. Europe abounds in pickpockets, so one should be alert for any efforts to divert your attention. In addition to not having any valuables accessible, another defense is to scream, ‘Go away!’ in the native language. Then the pickpockets, especially children, know that you are not an ‘innocent abroad.’”

“You can do that?”

“In French, German, Italian, and when we were there, in Czech. That’s why I now always travel with Mrs. Curmudgeon; despite her bad experience she still chooses not to learn (or re-learn) any of those languages.”

Affinity’s Kaizen Curmudgeon

(1) Hallinan Joseph T. Why We Make Mistakes (Broadway Books, 2009)
(2) Croskerry, Pat http://journals.lww.com/academicmedicine/Fulltext/2003/08000/The_Importance_of_Cognitive_Errors_in_Diagnosis.3.aspx

(3) http://psnet.ahrq.gov/printviewPrimer.aspx?primerID=12

Check out the latest posting in Curmudge and Jaded Julie’s personal blog, Curmudgeon’s Wastebasket.