Getting Unstuck: Creative Problem Solving

1. Getting Unstuck:Creative Problem Solving Ken Abrams, Ph.D.You-Know

2. Objectives • Explore why we need to be creative and how to get that way • Propose a method to leverage new technology to improve problem solving creativity

3. The Challenge Think different!

4. To get better solutions, we need to • Escape from pre-conceptions • Come up with more creative, complete solutions that fit more of the data

5. Creativity: Why now? • Internet • Disseminating ideas and innovation • Place to find knowledge and express opinion • Universalizing access to education • Speeding globalization • Flattening the world • New technology challenges and threats • Genetic engineering • Nano-technology • Pressing need for alternative energy • Deal with global warming • Discover opportunities • Healthcare • More effective use of resources • More efficient delivery and payment • Security • Clash of civilizations • Understand other cultures and thinking • Cross-culture collaboration

6. Markets that need more creative problem solving: • Military • Government • Non-profits • NGOs • Medicine • Education • Automotive • Energy

7. Brief History of Problem-SolvingCreativity

8. Problem: Tie together two ropes hanging too far apart to grab at the same time Solution: Use wrench as a pendulum weight to swing distant rope within reach Functional Fixedness (Maier 1931) • Inability to use an object in an atypical way to solve a problem: stuck in the frame • Increase effect • If S tightens a nut with the wrench, less likely to see new use • Decrease effect • If E bumps into rope and starts it swinging, S is more likely to use wrench as a pendulum weight

9. Alternative Uses (of a Brick) Task Guilford 1967 • Originality • Fewer people who give a response, the more original • Fluency • Total number of ideas • Flexibility • Number of different categories ideas fall into • Elaboration • Detail of each idea

10. Remote Associates Test Mednick & Mednick 1967 • Measures ability to find a common word or concept that links three otherwise unrelated words • Example • “Falling Actor Dust” STAR

11. Step 1. Goal finding D: What do we want? C: Rank importance. Step 2. Fact finding D: What need to know? C: Which first issues? Step 3. Problem finding D: How to? Challenge? C: Work on which? Step 4. Idea finding D: New ways to do this? C: Best ideas? new? risky? Step 5. Solution finding D: Decision points? Value? C: Most relevant? Likely succeed? Step 6. Acceptance finding D: Obstacles? Aids? C: Change needed? Success measures? Implement steps? Divergent/Convergent Problem Solving: Brain-storming (Osborn & Parnes 1967)

12. Lateral ThinkingdeBono 1971 • To break out of functional fixedness, and come up with new solutions, start with a new thought, a new metaphor • Lateral Thinking: techniques for generating a new starting place to create a novel solution • Recognize dominant ideas • Search for different perspectives • Relax control • Use chance to create new starting points

13. Watanabe’s Ugly Duckling Theorem • Any one thing has an infinite number of attributes • Any two things have an infinite number of attributes in common and an infinite number of attributes in only one • Similarity is selecting the set of attributes to look at. Choosing Set 1 vs. Set 2: yields different similarity levels • Similarity is in the eye of the beholder; it is not intrinsic in the objects themselves • Perception and thought affect judgment, because one set of attributes is favored over another

15. People prefer avoiding a loss over making a gain Availability Judged likelihood is proportional to how easy it is to think of relevant (recent) examples Confirmatory bias Once have a hypothesis, then accept only confirmatory data Gambler’s fallacy Random event is less likely to occur again, because it happened recently Biases in Decision-Making Under Uncertainty (Tversky & Kahneman 1973)

16. Judgments of emotional tone are fast (Gladwell) • Expert can assess emotion in person or relationship in two seconds • Fast, efficient unconscious processing • Students can decide how good a professor is from 2 sec of video tape: After 2 sec judgment is highly correlated with judgments after a semester w. prof • Expert can identify the style and emotional valence of a person or relationship in seconds • By walking through a person’s home • By viewing video of a married couple

17. Instinctive Expert: “thin slicing” • Makes accurate perceptual judgments, takes quick effective action, executes skilful movement • Can’t explain how she knows or performs • Fraud experts, tactical battalion commanders, CEOs, athletes, machinists, poets, performing artists • Knowledge is the act of perception or performance • There is no knowledge of how the act is performed • Knowledge is not structured as verbal principles • Non-verbal knowledge is not accessible for general problem solving • Not committed to theory: pragmatic, quick • Disconnect between verbal explanation and non-verbal knowledge • Explanation distracts from the task and degrades performance

18. Synthesizes multiple channels of data Visual, tactile, text, numerical, computational Writes reports and papers Doctor, lawyer, academic, other professional, guru Organizes knowledge in a verbal representational structure under general principles Even if supporting evidence or data is non-verbal Knowledge is verbal and accessible for solving problems That can be represented in natural language Can articulate principles or evidence behind one’s thinking Because knowledge representation is organized under general principles and is verbal Invested in the structure of one’s knowledge Gives up theory only with extreme reluctance Systematic Expert

19. Systematic vs. Instinctive expertise • Best judgments are a balance of both • Depends on the domain • Diagnosis (internal medicine, military strategy) = systematic • ER triage and stabilization = instinctive • Dynamic (skiing, skirmishing, performing) = instinctive • Judging emotional relatedness (sales, interaction) = instinctive • Articulating cues in face to face interaction = systematic

20. Physicians making decisions • Rapid decisions (minutes) • Surgeons suppress uncertainty through action • Emergency physicians: act fast to stabilize • Radiologists: pressured by referring doc to commit to diagnosis • High case load forces rapid decision • Describing observations with no immediate relevance to the question asked can have value, but it takes longer

21. Physicians making decisions • Systematic decisions • Cardiology Algorithm (decision tree of best practices) is most accurate predictor of which patient is having a heart attack at the moment • Enforces systematic approach • More accurate than non-experts • Extra information reduces accuracy

22. Systematic decisions: encourage others adopt (Welch 2005) • Leaders should probe and push with a curiosity that borders on skepticism… • Every conversation ..about a decision, a proposal, or .. market information has to be filled with .. “What if?” “Why not?” and “How come?”

23. How Doctors Think (Groopman) • Even the most accomplished physician can miss a key clue about a person’s true diagnosis • Misdiagnosis is a window into the medical mind revealing why • Doctors fail to question assumptions • Their thinking is closed or skewed • They fall into cognitive traps • Deliver poor care • More than15% of all diagnoses are inaccurate (Comparing diagnosis with autopsy, 1995)

24. Cognitive errors • Framing bias • Doctors use shorthand to categorize patients • I have a case of diabetes and renal failure • I have a drug addict here in the ER with fever and a cough from pneumonia. • Accepting frame as given can be a serious error, because • A frame sticks esp. when pronounced by an expert • An erroneous frame constrains thinking delays an accurate diagnosis, sometimes for years

25. Senior Attending: instinctive decisions • When encountering a patient in an emergency: doesn’t reason at all • Expert clinician forms idea of what’s wrong in 20 seconds • Pattern recognition: immediate perception leads to a gestalt • Physician begins diagnosis from the first second • Pallor or ruddiness, tilt of head, movement of eyes and mouth, how sits and stands, timbre of voice, depth of breathing • Notions of what is wrong evolve in the next minutes • Peer into eyes, listen to heart, press the liver, inspect initial x-rays • Come up with 2-3 possible diagnoses from the outset of meeting a patient • Talented docs use heuristics to generate 4-5 diagnoses from incomplete information

26. Cognitive errors • Attribution error • Patient fits negative stereotype (alcoholic, drug user, vagrant,…), rather than someone who can’t respond because he’s ill • Representativeness error (framing) • Thinking constrained by a prototype: no contradictions considered

27. Cognitive errors • Availability error • Diagnosis comes readily to hand, because one’s seen numerous cases of this infection or this addiction over recent weeks • Pattern recognition is distorted by local ecology • Confirmation bias: • Strong belief in hypothesis causes cherry-picking to find data that fits and ignore data that doesn’t • Anchoring • Latch onto a single possibility, confident that the anchor has been thrown down just where it needs to be • Don’t consider alternate explanations • Leads to skewed reading of the facts • Ex: Estrogen helps with menopause • Gynecologists and cardiologists are on opposite sides

28. ER: rapid action is valued, but systematic works better • Swift and decisive action saves lives, BUT • Studied calm - consciously slowing thinking and action - avoids being distracted by the chaotic atmosphere • Shooting-from-the-hip causes anchoring and availability bias • Can lead to misdiagnosis • Ask What’s the worst it can be? To slow down and broaden thinkingOpportunity: Intelligent diagnostic aid

29. Cognitive errors • Momentum of the diagnosis (band-wagon effect) • Once an expert (specialist) fixes a label to the problem, it stays attached, because the expert is usually right • Worked-up the yin-yang error • Multiple specialists and tests discourage innovative divergent thinking • What new could be possibly found? • Denial of uncertainty • Retain control by making the world more certain • Even at the expense of falsifying data • Denying uncertainty makes action possible: breaks paralysis

30. Cognitive errors • Commission bias • Move toward action, rather than inaction • When over-confident, ego inflated, desperate • But no action can be the best course • Satisfaction of search error • Search stops when first thing is found • But may be more than one thing to be found

31. Cognitive errors • Inside-the-box error • Can’t think fresh, when test and clinical data don’t fit • Sometimes have to investigate multiple causes to explain the data • Ask What else could this be? • Even in face of the obviousOpportunity: Intelligent aid

32. Conclusions about cognitive errors • ER doctors: shoot-from-the-hip instinct is prized • Radiologists: finding “the gestalt” is a mark of good training • Studies of radiologists show high error rates • Going on first impressions missed important findings • Screen for normality: 60% failed to note a clavicle was missing • Searching cancer (look at all structures carefully): 17% failed to note missing clavicle • Confidence is no indicator of accuracy • Poor performers were as confident as best • Average diagnostic error interpreting medical images = 20-30% • Studies of internists show high error rate • Physical exam for cyanosis: 73% error • Reading EKG for myocardial infarction and other abnormalities: 46% error

33. How to avoid errors • Radiology • Slow down the process of perception and analysis • Be systematic • Note observations before drawing conclusions: sometimes an exact diagnosis can’t be made: resist over-diagnosing • Provide the complete clinical story; don’t ask for an answer to a single focused question • Generate a short list of alternatives • Use a structured checklist • Observations that seem irrelevant can have clinical import • Going with your gut sometimes doesn’t work • A checklist forces one to work in a stepwise way. It leads to more accurate diagnosis, even though examining the image to address only the specific question asked is quicker. • Use computer assistance • Improved detection of cancer: decreased false negatives 14-24%, but increased false positives 10%

34. How to avoid errors • Radiology • Train experts to use a controlled vocabulary • Calibrate language to code perception accurately and consistently • Clarifies what is NOT implied • “X is not enlarged” /=> X is normal • Computer enhance the image to improve contrast • Clear border rather than blurry edge • Boost clarity of “objects” in normal tissue

35. A New Approach

36. Develop intelligent aids • Capture best practice algorithms • Includes hints and suggestions to encourage lateral thinking to explore alternate causes of observed data • Solicits input from experts in the community of practice to resolve or synthesize standards of treatment in different hospitals and regions • Pushes relevant vetted studies to the clinician as she works on the diagnosis • Uses sharing over the Internet to unify the standard of care within a national (or international) community of practice based on empirical studies of outcome • Allows clinician with a difficult case to request input from experts with relevant experience

37. Advantages and Benefits • Brings new ideas to the table; new starting points, new combinations • Information and opinions are drawn from an expanded range of starting assumptions and different regions of the problem space; a wider range of perspectives • More interaction and synthesis of ideas • Develops a persistent repository and an audit trail of what ideas went into a decision • Transparency (can be set at different levels, but more is better) • Encourages clinicians to consider a wider range of considerations in their solutions

38. Considerations • How can this approach deliver enough value in more efficient diagnosis and treatment to have it adopted by clinicians throughout the community practice? • How will payers react? • How to accelerate adoption? Become a standard of best practice? Cf. InterQual • Can the system if adopted by the COP, become a channel of wider collaboration?

39. Contact • Ken Abrams, Ph.DYou-KnowTel 617-519-0500kabrams@you-know.com