Tuesday, February 19, 2013

Metacognition For The Pragmatist

The Gist: Metacognition and cognitive errors in medicine are not merely fluffy, esoteric ideas. There are concrete steps one can take to mitigate these. Check out the Ten Commandments To Reduce Cognitive Error and Ten Commandments To Reduce Diagnostic Error by Dr. Leo Leonidas.

As a student, my interests lie in the "meat" (or tofu, as it were) of medicine. Yet, as the breadth (minute as it is) of my clinical experience grows, I've become increasingly interested and aware of cognitive errors, especially my own. Why? Well, I think it will make me a better future physician. Cognitive bias, previously discussed here, is common in medicine and emergency medicine (EM). Metacognition, discussed in this post, can mitigate cognitive error by evaluating one's thinking. Although this seems esoteric, especially to the trainee, there are some concrete ways to go work through this process.

Commandments to reduce cognitive and diagnostic errors
Adapted from Dr. Leo Leonidas (1,2)

Thou shalt think of serious and treatable conditions and act on them without delay

  • This is the crux of EM.  We must be facile with some of the most intense minutes of every specialty - retrobulbar hematoma, subarachnoid hemorrhage, asthma, cardiac arrest, or...anything! 
  • Know the killers and, as I learned from this EMBasic episode, always place a few in the differential.  

Thou shalt mentally rehearse common and serious conditions that you expect to see in your specialty.
  • Simulation plays an expanding role in medical education, especially in EM where physicians must be skilled in life and limb-saving procedures that are rarely used. Preparation is crucial to making logical decisions under pressure and time constraints. Check out this paper by Dr. Cliff Reid (full text).
  • There is a cornucopia of FOAM procedure videos and tips, available regardless of one's proximity to a fancy simulation center . Examples include: Life In The Fast Lane repository, Procedurettes, EMCrit's Thoracotomy Episode, and so many more out there (use EMgoogle).
Thou shalt not rely on your memory when making critical decisions.
  • Check the actual vitals, labs, etc when making crucial decisions or talking with consultants. EDs are insanely busy and it's difficult to keep things straight, no matter how sharp the mind.  
    • I overheard a conversation in which a PCP received a call to admit a syncope patient and, when the PCP asked about the patient's blood pressure, the ED doctor stated it was "about 150's systolic." Upon review of the patient's chart, her systolic BP was 90mmHg throughout her ED stay. This misinformation didn't result in harm, but it certainly pointed to potential cause of syncope and a lack of attention to detail.
Thou shalt consider other possibilities even though you are sure of your first diagnosis.  
  • Always think of a differential, even if it's a "slam dunk" case. This can help avoid anchoring bias as well as diagnostic momentum bias.
  • Continue the debate and questioning even though the data is “in,” this will help mitigate confirmation bias and premature closure (see ALiEM post). 
Thou shalt maintain a high index of suspicion or uncommon presentations of the common.
  • Know the probability and epidemiology of the diseases in the your differential but, in order to lessen availability bias, also recognize that zebras exist.  Include one in each differential, it's a great thought exercise and the diagnosis doesn't have to be worked up fully solely because it's on the differential.   
  • Patient's often don't present in the "classic" or "textbook" way.  According to Dr. Amal Mattu, "Classic, in medicine, means 15% of the time."  Sounds about right.
Thou shalt be wary of your hunches and intuitions; use Evidence Based Medicine (EBM).  
  • Gestalt plays a huge role in EM.  As discussed in this post, however, this is something that evolves over the course of an entire career and is something that trainees like myself are fiercely trying to cultivate. 
  • Clinical experience and anecdotes play a formative role in the development of a physician yet come at a price.  We are more likely to remember the 1 in 1,000,000 exception than the mundane 999,999.  These make great stories and provide learning points, but we probably shouldn't become reactionary to the outlier.    
  • EBM is not infallible and there are instances in which there is insufficient, applicable evidence to guide decision making.  However, in many cases there is a body of global experience with a particular disease or intervention.  It would be foolish to not capitalize on the best available information to provide the best patient care.
Thou shalt take time to decide.
  • At the end of a night shift with a packed waiting room, it may be worth pausing for a moment to think about the 55 year old with abdominal pain. Reconstruct the story without segments spent dealing with the combative drunk, the code, and the literal pain in the neck. There are situations in which action is paramount; however, in most cases there's time to think. 
 Thou shalt engage in accountability procedures and follow up for decisions. 
  • Follow patients - it's a myth that emergency physicians can not or should not engage in follow up.
    • Keep a protected list of patients for each shift - using logs, stickers, or lists in the medical record software. 

Thou shalt request a test only if it will change your plan or help in predicting the outcome.

  • Danger exists in too much information as it can lead one astray.  Think about how a test is relevant and will change management (ALiEM post). The pieces must fit, otherwise an extraneous bit of information could lead to search satisfying bias. 
  • Testing and treatment has associated risks, for a review, see the St. Emyln's posts on this topic.
  • Diagnosis is largely in the history and physical exam, make sure that the data fits with the story and the patient's clinical exam and vice versa.  As trainees, it's crucial to hone the history and physical skills, particularly for short ED encounters. 
Thou shalt use available databases.

  • Use an iPad, tablet, or iPhone to readily access information. Consult applications, calculators, and pharmacopeias to double check medication dosages and adverse effects.
  • Colleagues often have niches - in ECGs, stroke, toxicology, etc. Pause to run cases by others for a fresh or alternative perspective.  
  • Lucky enough to have an ED pharmacist? Consult with them to reduce error (Patanwala et al, Cohen et al).
  • Electronic medical records systems allow one to view recent hospital visits and lab work, helpful in piecing together a coherent story.
  • Prescription monitoring databases can be a valuable resource. ACEP recommends using them (Level C).

Thou shalt reflect on how you think and decide.
  • Recognize your own beliefs, biases, prejudices, and thinking style.  This is one of the toughest commandments, as it requires introspection and reflection.  For example, I know that I often have the tendency to mentally apply EBM and literature before fully assessing a patient's nuances.  Knowing this, however, I benefit from a mental pause checkpoint.  
  • Check out talks from FreeEmergencyTalks.net on this by Dr. Croskerry.
  • Heuristics, often cultivated by gestalt, are frequently used in medicine.  Check out these articles by Wegwarth et al and Marewski to see some ways in some ways in which heuristics can be created and tweaked to as a form of decision support.  


1.Leonardo Leonidas.  "Ten Commandments to Reduce Diagnostic Errors."  Given to the Class of 2001 Tufts University School of Medicine From Dr. Leonardo Leonidas, Bangor, Maine, 20 May 2001  

2.Leonardo Leonidas. "Ten Commandments to Reduce Cognitive Errors."  2003.


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