Critical thinking and its impact of patient safety

1. Critical thinking and its impact of patient safety Pat Croskerry MD, PhD Patient Safety Officer Course CPSI, Ottawa April 2011

2. ‘Life is short, opportunities of knowing rare; our senses are fallacious, our reasonings uncertain; man therefore struggles with perpetual error from the cradle to the coffin.’ Erasmus Darwin, Zoonomia, 1794

3. This session is a focus on our most important faculty How we think

4. Seven Quick QuestionsTake a piece of paper and write down your answers to each of these 7 questionsYou have about 10 seconds for each response

5. 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?

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

7. 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?

8. A bat and a ball cost $1.10 in total. The bat costs $1.00 more than the ball. How much does the ball cost?

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

10. In a lake, there is a patch of lily pads. Every day, the patch doubles in size. If it takes 48 days for the patch to cover the entire lake, how long would it take for the patch to cover half the lake?

11. 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

12. Answers • 30 • 2 • 46½ hours _________________________________ D. The ball costs 5¢ and the bat $1.05 E. 5 minutes F. 47 days G. Jack is a lawyer

13. 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

14. Cognitive Reflective Test • The test distinguishes intuitive from analytical processing • It tests the ability to resist first response that comes to mind • Of 3428 people tested only 17% got all 3 correct • 33% answered all three incorrectly Frederick 2002 (MIT)

15. The only decision we must make in our lives is how to live our livesL.J.Savage, 1954 ‘How to live our lives’ means ‘How to make decisions’ Gigerenzer et al, 2002

16. What do we know about decision making?

18. 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

19. Extra-Sensory Perception?

20. James Randi Educational FoundationFirst offer of $1000 for proof of any psychic/paranormal event made in 1964Now $1,000,000(unclaimed) James Randi Educational Foundation201 S.E. 12th StreetFort Lauderdale, FL 33316-1815 USA

21. How well do we make decisions?

22. A review of the (popular) literature

24. What factors adversely affect decision making? • Biases • Information gaps • Ambient conditions • Context • Availability of resources • Well-being of decision maker • Cognitive loading • Fatigue, sleep deprivation

25. Healthcare is not rocket scienceIt’s a lot more complicated…

26. How might we think more critically?

27. Critical Thinking • Knowledge of how we reason and make decisions • To be able to recognize distracting stimuli, propaganda, irrelevance • To know and understand cognitive and affective bias • Ability to identify, analyze, and challenge assumptions in arguments • Ability to recognize deception, deliberate or otherwise • Capability to assess credibility of information • Ability to monitor and control own thought processes • Ability to imagine and explore alternatives • Understanding of how to effectively work through problems • Capacity for making effective decisions

29. We have a new way of looking at decision making It can be applied to all decision making in healthcare

30. Type 1 and Type 2processes(dual process theory)

31. Type 1 (intuitive) Cognitive style Heuristic Cognitive awareness Low Cost Low Automaticity High Rate Fast Reliability Low Errors Usually Effort Low Predictive power Low Emotional component High Scientific rigour Low Type 2 (analytical) Systematic High High Low Slow High Few High High Low High

32. Neuroanatomical correlates • Type 1 processes:ventromedial prefrontal cortex, nucleus accumbens, amygdala, and lateral temporal cortex • Type 2 processes: prefrontal cortex, hippocampus and medial temporal lobe, posterior parietal cortex

33. X4 C2 C3 X3 X2 X1 C1 X4

34. Type 1 processing automatic and effortless (35 to 55 Hz) Type 2 processing requires effort (22 to 34 Hz) PREFRONTAL CORTEX PARIETAL CORTEX MT “Spatial” attention (25 to 45 Hz) V4 Color identification (60 Hz)

35. A schematic model for how the systems work together

37. TYPE 1 processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Rational override Dysrationalia override Calibration Diagnosis Repetition TYPE 2 processes NOT RECOGNIZED

39. Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override Dysrationalia override T Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED

40. System 1 RECOGNIZED Expertise Proficiency Initial percept or problem Pattern Processor Competence Calibration Calibra Decision Advanced Beginner Novice System 2 NOT RECOGNIZED

41. Toggle Function(Hypothesis Hopping)

42. Type 1 Processes RECOGNIZED Pattern Recognition Patient Presentation Pattern Processor Executive override T Dysrationalia override Calibration Diagnosis Repetition Type 2 Processes NOT RECOGNIZED

43. 6 Main Features of the Model • Toggle function • Most errors occur in System 1 • Repetitive operations of System 2 >>> 1 • System 2 override of System 1 • System 1 override of System 2 • Cognitive Miser function

44. BMJ Nov 2010

45. 2005

46. ‘We really only trust conscious decision making. But there are moments, particularly in times of stress, when haste does not make waste, when our snap judgments and first impressions can offer a much better means of making sense of the world. The first task of Blink is to convince you of a simple fact: decisions made very quickly can be every bit as good as decisions made cautiously and deliberately’ P 14 BlinkMalcolm Gladwell (2005)

47. 2006

48. ‘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 12 ThinkMichael Legault (2006)

49. The power of Type 1 processes