The Cognitive Autopsy

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We are in a thinking profession.  

An outsider looking in on our profession may see procedures and action as the defining characteristics of the practice of Emergency Medicine.  But, reflecting on the attributes of the best EM docs I’ve worked with, their procedural excellence isn’t what stands out.  Thinking back on the great physicians I have met and worked with, the ones I strive to be like every day, it is their ability to think, lead, and educate that sticks with me the most.  

And, it turns out I’m not the only one who might see it like this…

If thinking and decision making is a crucial component to becoming a master clinician, we must know tons about how to teach that to our trainees and to ourselves right?  Not exactly.  For procedural skills, the teaching process is pretty well defined - break down the procedure into its constituent micro-tasks, deliberative practice on simulation task trainers, supervised performance on a real patient, then independent practice with self-reflection until you can perform the procedure blindfolded, in the dark, upside down, with someone screaming in your ear…

For learning (and teaching) clinical decision making the process is much less well defined.  In one possible approach, Croskerry, Wears, and Binder (2000) outlined their approach to a curriculum for error prevention in Emergency Medicine (1).  In addition to proposing a multidisciplinary approach highlighting the importance of communication, team dynamics, and feedback, they also emphasize the need for “educational initiatives directed toward individual response to error” and identifying “meaningful patterns in practice that indicate impending error.”  Croskerry has also written extensively on the importance of understanding cognitive errors (termed cognitive dispositions to respond) and cognitive forcing strategies in developing excellence in clinical decision making (2, 3, 4).  Though there is some evidence that, at least in a simulated environment, cognitive forcing strategies might not lead to a decrease in diagnostic error (5).  I would posit that, at a minimum, knowledge of cognitive biases/errors and of the mental processes involved in clinical decision making, can (or at least should) lead to improved, more resilient, clinical decision making.

But, how do we go about learning cognitive biases (also termed cognitive errors, also termed cognitive dispositions to respond)? Well, you could go to the wikipedia page that has an extensive listing of biases and learn one per day… for the next 165 days… (6).  To best learn these cognitive biases, we need to situate them and tie them to real world clinical experiences.  Croskerry outlined a process to do just that termed a “cognitive autopsy.” (7)  In the podcast below, the process of this autopsy is outlined and an example clinical case, rife with cognitive biases, is presented by Dr. Ryan Gerecht.

References

  1. Croskerry, P., Wears, R., & Binder, L. (2000) Setting the Educational Agenda and Curriculum for Error Prevention in Emergency Medicine. Academic Emergency Medicine. 7 (11). 1194-1200.
  2. Croskerry, P. (2002) Achieving Quality in Clinical Decision Making: Cognitive Strategies and Detection of Bias.  Academic Emergency Medicine. 9 (11). 1184-1204.
  3. Croskerry, P. (2003) Cognitive Forcing Strategies in Clinical Decision Making. Annals of Emergency Medicine. 41 (1). 110-120.
  4. Kovacs, G. & Croskerry, P. (1999) Clinical Decision Making: An Emergency Medicine Perspective. Academic Emergency Medicine. 6 (9). 947-952.
  5. Sherbino, J. Kulasegaram, K. Howey, E, & Norman, G. (2014) Ineffectiveness of cognitive forcing strategies to reduce bias in diagnostic reasoning: a controlled trial. CJEM. 16 (1). 34-40.
  6. List of cognitive biases. (2015, February 18). In Wikipedia, The Free Encyclopedia. Retrieved 03:34, February 27, 2015, from http://en.wikipedia.org/w/index.php?title=List_of_cognitive_biases&oldid=647717280
  7. Croskerry, P. (2009) “The Cognitive Autopsy.” Patient Safety in Emergency Medicine. Lippincott Williams & Wilkins. Ch. 42. 302-307.