Critical thinking Critical thinking and its impact of patient safetyand its impact of patient safety

Pat Croskerry MD, PhDPat Croskerry MD, PhD

Patient Safety Officer CourseCPSI, Ottawa April 2011

‘Life is short, opportunities of knowing rare; Life is short, opportunities of knowing rare; our senses are fallacious, our reasonings our senses are fallacious, our reasonings uncertain; man therefore struggles with uncertain; man therefore struggles with

perpetual error from the cradle to the coffin.’perpetual error from the cradle to the coffin.’

Erasmus Darwin, Zoonomia, 1794

This session is a focus on our most important faculty

How we think

Seven Quick QuestionsSeven Quick Questions

Take a piece of paper and write down your answers to each of these 7 questions

You have about 10 seconds for each response

On a standard Ottawa fire truck, there are 2 drivers up front, one at the rear and

three additional fire-fighters. What is the total personnel required for 5 standard

trucks?

How many turtle doves did my true love send me on the 2nd day of Christmas?

In 2010, the average time required to complete a root cause analysis was 15½

hours, how much time should be allowed for the three that are expected next

month?

A bat and a ball cost $1.10 in total. The bat A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. costs $1.00 more than the ball.

How much does the ball cost?How much does the ball cost?

If it takes 5 machines 5 minutes to make 5 widgets, how long would it take 100

machines to make 100 widgets?

In a lake, there is a patch of lily pads. In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it Every day, the patch doubles in size. If it takes 48 days for the patch to cover the takes 48 days for the patch to cover the

entire lake, how long would it take for the entire lake, how long would it take for the patch to cover half the lake?patch to cover half the lake?

In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study.Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs

What is most likely? a. Jack is an engineer b. Jack is a lawyer

De Neys & Glumicic, 2008

Answers

A.A. 3030B.B. 22C.C. 4646½ hours½ hours__________________________________________________________________D. The ball costs D. The ball costs 5¢ and the bat $1.055¢ and the bat $1.05E. 5 minutesE. 5 minutes F. 47 daysF. 47 daysG. Jack is a lawyerG. Jack is a lawyer

In a study 1000 people were tested. Among the participants there were 5 engineers and 995 lawyers. Jack is a randomly chosen participant of this study.Jack is 36 years old. He is not married and is somewhat introverted. He likes to spend his free time reading science fiction and writing computer programs

What is most likely? a. Jack is an engineer b. Jack is a lawyer

De Neys & Glumicic, 2008

Cognitive Reflective Test

• The test distinguishes intuitive from analytical processingThe test distinguishes intuitive from analytical processing• It tests the ability to resist first response that comes to mindIt tests the ability to resist first response that comes to mind• Of 3428 people tested only 17% got all 3 correctOf 3428 people tested only 17% got all 3 correct• 33% answered all three incorrectly33% answered all three incorrectly

Frederick 2002 (MIT)Frederick 2002 (MIT)

The only decision we must make in our The only decision we must make in our lives is how to live our liveslives is how to live our lives

L.J.Savage, 1954L.J.Savage, 1954

‘‘How to live our lives’ meansHow to live our lives’ means ‘ ‘How to make decisions’How to make decisions’

Gigerenzer et al, 2002Gigerenzer et al, 2002

What do we know What do we know about decision making?about decision making?

How well do we How well do we make decisions?make decisions?

A few examples• More than half of marriages fail• Chances of winning the lottery are 14,000,000:1• Most newspapers carry astrological forecasts• All gambling systems are carefully designed to beat you, yet…• Half the US population believes the universe is 6000 years old• Most people think they are above average drivers• We become addicted to many known harmful things• Nations go to war to settle differences of opinion• People universally believe their god is better than other gods• 160 million have died in the last century over religious disputes• 10 - 30% of children do not have the father they think they have• 37% of US believe creationism should be taught instead of evolution• Most university professors think their research area is more important• Half the US population believes in UFOs• 40% of Canadian Mensa believes in UFOs• 9 million Americans reach the criterion for morbid obesity• More than 6 out of 10 people believe in extra sensory perception

Extra-Sensory Perception?Extra-Sensory Perception?

James Randi Educational FoundationJames Randi Educational Foundation

First offer of $1000 for proof of any First offer of $1000 for proof of any psychic/paranormal event made in 1964psychic/paranormal event made in 1964

Now $1,000,000Now $1,000,000(unclaimed)(unclaimed)

James Randi Educational Foundation201 S.E. 12th Street

Fort Lauderdale, FL 33316-1815 USA

How well do we make decisions?How well do we make decisions?

A A review of the review of the

(popular) literature(popular) literature

What factors adversely What factors adversely affect decision making?affect decision making?

• Biases• Information gaps• Ambient conditions• Context• Availability of resources• Well-being of decision maker• Cognitive loading• Fatigue, sleep deprivation

Healthcare is not rocket scienceHealthcare is not rocket science

It’s a lot more complicatedIt’s a lot more complicated……

How might we think more critically?How might we think more critically?

Critical ThinkingCritical Thinking• Knowledge of how we reason and make decisionsKnowledge of how we reason and make decisions• To be able to recognize distracting stimuli, propaganda, To be able to recognize distracting stimuli, propaganda,

irrelevanceirrelevance• To know and understand cognitive and affective biasTo know and understand cognitive and affective bias• Ability to identify, analyze, and challenge assumptions in Ability to identify, analyze, and challenge assumptions in

argumentsarguments• Ability to recognize deception, deliberate or otherwiseAbility to recognize deception, deliberate or otherwise• Capability to assess credibility of informationCapability to assess credibility of information• Ability to monitor and control own thought processesAbility to monitor and control own thought processes• Ability to imagine and explore alternativesAbility to imagine and explore alternatives• Understanding of how to effectively work through problemsUnderstanding of how to effectively work through problems• Capacity for making effective decisionsCapacity for making effective decisions

We have a new way of looking at decision making

It can be applied to all decision making in healthcare

Type 1 and Type 2Type 1 and Type 2processesprocesses

(dual process theory)(dual process theory)

Type 1 (intuitive)

Cognitive style HeuristicCognitive style HeuristicCognitive awareness LowCognitive awareness LowCost LowCost LowAutomaticity HighAutomaticity HighRate FastRate FastReliability LowReliability LowErrors UsuallyErrors UsuallyEffort LowEffort LowPredictive power LowPredictive power LowEmotional component HighEmotional component HighScientific rigour LowScientific rigour Low

Type 2 (analytical) Systematic High High Low Slow High Few High High Low High

Neuroanatomical correlates

• Type 1 processes:Type 1 processes: ventromedial prefrontal cortex, nucleus accumbens, amygdala, and lateral temporal cortex

• Type 2 processesType 2 processes: prefrontal cortex, hippocampus and medial temporal lobe, posterior parietal cortex

C1

C3C2

X1X1X2X2

X3X3

X4X4

X4X4

Type 2 processingrequires effort(22 to 34 Hz)

PREFRONTAL CORTEX

PARIETAL CORTEX

Type 1 processingautomatic and effortless

(35 to 55 Hz)

“Spatial” attention(25 to 45 Hz)

Color identification(60 Hz)

V4

MT

A schematic model for how A schematic model for how the systems work togetherthe systems work together

Pattern Recognition

Repetition

Rationaloverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

TYPE

11processes

TYPE

22processes

NOTRECOGNIZED

Pattern Recognition

Repetition

Executiveoverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

Type11

Processes

Type22

Processes

T

Calibra Decision

Initialpercept

or problem

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

System11

System2

Novice

AdvancedBeginner

CalibrationCompetence

Proficiency

Expertise

Toggle Function

(Hypothesis Hopping)

Pattern Recognition

Repetition

Executiveoverride

Dysrationaliaoverride Calibration Diagnosis

PatientPresentation

PatternProcessor

RECOGNIZED

NOTRECOGNIZED

Type11

Processes

Type22

Processes

T

66 Main Features of the Model Main Features of the Model

• Toggle functionToggle function• Most errors occur in System 1 Most errors occur in System 1 • Repetitive operations of System 2 >>> 1 Repetitive operations of System 2 >>> 1 • System 2 override of System 1System 2 override of System 1• System 1 override of System 2System 1 override of System 2• Cognitive Miser functionCognitive Miser function

BMJ Nov 2010

20052005

BlinkBlink Malcolm Gladwell (2005)Malcolm Gladwell (2005)

‘‘We really only trust conscious decision making. But We really only trust conscious decision making. But there are moments, particularly in times of stress, there are moments, particularly in times of stress, when haste does not make waste, when our snap when haste does not make waste, when our snap judgments and first impressions can offer a much judgments and first impressions can offer a much

better means of making sense of the world. The first better means of making sense of the world. The first task of task of Blink Blink is to convince you of a simple fact: is to convince you of a simple fact: decisions made very quickly can be every bit as decisions made very quickly can be every bit as

good as decisions made cautiously and deliberatelygood as decisions made cautiously and deliberately’

P 14P 14

20062006

ThinkThink Michael Legault (2006)Michael Legault (2006)

‘The technique by which we make good decisions and produce good work is a nuanced and interwoven mental process involving bits of emotion, observation, intuition, and critical reasoning. The emotion and intuition are the easy, “automatic” parts, the observation and critical reasoning skills the more difficult,

acquired parts. The essential background to all this is a solid base of knowledge.’

P 12P 12

The power of The power of Type 1 processesType 1 processes

Swallowing salivaSwallowing saliva

Would you drink a glass Would you drink a glass of your own saliva?of your own saliva?

The emotion of disgust (System 1) The emotion of disgust (System 1) overcomes rational input (System 2)overcomes rational input (System 2)

How can we improve decision How can we improve decision making making

in healthcare?in healthcare?

You aren’t thinking critically enough, so be You aren’t thinking critically enough, so be more carefulmore careful

The occasional slap might wake some people up

Other factors that may acutely Other factors that may acutely compromisecompromise

clinical decision makingclinical decision making

• FatigueFatigue

• Illness, dysphoriaIllness, dysphoria

• Sleep deprivation, sleep debt, sleep inertiaSleep deprivation, sleep debt, sleep inertia

• Production pressures/RACQITOProduction pressures/RACQITO

• Group thinkGroup think

1010 things Dual Process Theory can do for us things Dual Process Theory can do for us• Provide a universal model for reasoning and decision making that Provide a universal model for reasoning and decision making that

embraces all approachesembraces all approaches• Provide a straightforward approach to teaching decision makingProvide a straightforward approach to teaching decision making• Explain how experience/practice leads to ‘automatic’ behaviorExplain how experience/practice leads to ‘automatic’ behavior• Explain how impulsive/irrational decision making occursExplain how impulsive/irrational decision making occurs• Explain how impulsivity/irrational decisions can be overriddenExplain how impulsivity/irrational decisions can be overridden• Show where cognitive and affective bias occursShow where cognitive and affective bias occurs• Explain how fatigue and sleep deprivation cause decision failuresExplain how fatigue and sleep deprivation cause decision failures• Predict cognitive miserly behaviorPredict cognitive miserly behavior• Predict where weaknesses in the decision making process occurPredict where weaknesses in the decision making process occur• Predict fruitful areas for researchPredict fruitful areas for research

How might we think more critically?How might we think more critically?

Critical ThinkingCritical Thinking• Knowledge of how we reason and make decisionsKnowledge of how we reason and make decisions• Able to recognize distracting stimuli, propaganda, irrelevanceAble to recognize distracting stimuli, propaganda, irrelevance• Recognition of eccentric and sociocentric thinkingRecognition of eccentric and sociocentric thinking• Intellectual humility Intellectual humility • To know and understand cognitive and affective biasTo know and understand cognitive and affective bias• Able to identify, analyze, and challenge assumptions in argumentsAble to identify, analyze, and challenge assumptions in arguments• Able to recognize deception, deliberate or otherwiseAble to recognize deception, deliberate or otherwise• Capability to assess credibility of informationCapability to assess credibility of information• Ability to monitor and control own thought processesAbility to monitor and control own thought processes• Ability to imagine and explore alternativesAbility to imagine and explore alternatives• Understanding of how to effectively work through problemsUnderstanding of how to effectively work through problems• Capacity for making effective decisionsCapacity for making effective decisions

‘‘Cognitive thought is the tip of Cognitive thought is the tip of an enormous iceberg. It is the an enormous iceberg. It is the

rule of thumb among cognitive rule of thumb among cognitive scientists that unconscious scientists that unconscious

thought is 95% of all thought – thought is 95% of all thought – this 95% below the surface of this 95% below the surface of conscious awareness shapes conscious awareness shapes and structures all conscious and structures all conscious

thought’thought’ Lakoff and Johnson, 19Lakoff and Johnson, 199999

Robin Hogarth

Educating Intuition

• Select/create decision–making environment• Improve feedback• Impose circuit breakers• Acknowledge emotions• Explore connections• Accept conflict in choice• Make scientific method intuitive