Stanford MedicineX: Medical Education in the New Millennium

this video was recorded in front of a live studio audience at Stanford University we're going to talk now about memory and cognition in medical decision-making I'm going to talk first about the traditional paradigm of medical education and how we think that we turn experiences into expertise let's take a little look at my funnel you can see that we expect in medical training to take personal experience such as patients that we take care of on the wards or possibly simulated patients or standardized patients and then we take vicarious experience by Carius experience includes patients that we care about in case based learning or problem-based learning conference might include patients we hear about in morbidity and mortality conference it also includes patients that we talk about with our colleagues over a cup of coffee and occasionally patients that we hear about on the news and then theoretical experience in the old-fashioned world this is sort of your book learning and I know in the modern day there's probably a lot more multimedia and fewer books but theoretical experience is the acquisition of those building blocks of cases that you have not seen but are intended to prepare you to recognize cases when they come up so reading podcasts videos lectures like you're doing here and the idea being that if we spend enough time taking care of patients and enough time going to conference and enough time reading our books that we're going to pop out at the other end of the medical education funnel with medical expertise throw a few monkey wrenches at this in just a few minutes because it's not so much what experiences we have but how we store and retrieve them so when we think about how we access our experience it's really important to understand that this is really a function of memory so if I hear about a patient or I take care of a patient or I read about a patient I have to store it and experiences are stored in the brain as gist's they are not stored as verbatim word for word ability to access that story it's a gist and the brain really likes to have something that's simple and coherent so remember simple short coherent that's what the brain likes you you don't have the details in your brain we're gonna speak about this a little more later if you don't have the details your brain is likely to make them up for you because it likes a complete picture as we get experience we make gist collections I've seen this just before I've seen it again the next time and eventually I have what's called a stereotyped illness script and if you guys read the pre reading on my blog you'll have already read a little bit about what an illness script is but it is essentially a pattern matching that an expert should be able to recognize immediately so when you come out the other end of your funnel and you have all of your experience and you find a pattern matched illness script you say to yourself really without a whole lot of thinking aha I know what that is I retrieve it from my memory it matches the illness script and you make your diagnosis you guys have learned a little bit earlier this year about type 1 and type 2 thinking but let's review it quickly there's intuitive and analytical thinking processes and our scripts are in the category of the type 1 process the fast thinking probably everybody in this room without thinking about it whatsoever knows that this is a cardinal on the right this is a cardinal or Lisa on your left that's a cardinal and you didn't even need to think about it it just came readily to mind you didn't need to do an assessment of the byrds features the beak geographically where the bird lives what does the bird like to eat we didn't need to think about any of those things because immediately you recognized it and knew what it was that's type 1 fast thinking the other bird you don't probably know what it is unless your birth scientist and so you might have to evaluate some of those features and once you've given careful consideration to those features you're going to have to consult some decision support so whether that be online or a book or an expert you're going to have to go through this in a deliberate way that requires significant mental effort let's think about what that looks like in a schema if you look at this image you can see that the first question is is the pattern recognized and for the Cardinal the answer is yep sure is and we go all the way over to decision you see we're on type one intuitive thinking and that arrow goes all the way to decision without doing anything else this happens almost in an instant and I like to call it non thinking because you're probably not even aware of doing any mental calculation if you don't recognize the pattern then we go into type two analytical thinking where we take all of the characteristics and we go to a calibration process where we consult our experts or we get online and then we make a decision and by the way in medicine everything starts off type two you're a new medical student you don't know any patterns you don't know any patterns at all but over time you can see I'm not sure if I can make this pointer work but over time you can see that type two analytical processes that are repeated become recognizable patterns so if you're following me up here become recognizable patterns and that is the process of learning and eventually as you become more and more expert things that you use to require mental effort now just seemed obvious here's the problem the number one cause of medical error in a diagnostic mistake happens right here pattern recognized up to 80% of diagnostic errors and patient harm are going wrong right there pattern recognized we say yes but the answer is actually no and the other problem that compounds all of this is pattern recognized we say yes and nothing happens we lay on done decision there are no safety nets there are no checks we're going to talk about that in order to know if we recognize a pattern we have to consult our memories and William Maxwell who was a very famous editor at The New Yorker has said what we refer to confidently as memory is really just a form of storytelling that goes on in the mind and changes with the telling what does he mean by that well we know our experiences are stored as memory and he says the memory changes with the telling let's think about that a little bit the data changes with the telling probably everybody can relate to the idea of loss of data you went to the store for six things you came home with four things what were the other two things you can't remember or someone's phone number you forgot that's easy you're sitting for a test and you're scratching your head saying I know I read that once I just can't remember so we lose data all the time that is easy to understand the next point of recall intrusion is a little bit more elusive to most folks this is the idea that data that was not actually part of the original event is recalled how does that happen if you think about the example of an eyewitness to a crime we know very often that those folks have a crystal clear image in their mind of what they believe that they saw they probably have some of those details wrong as we often find out later but the brain puts context coherent details in so if you can't remember the color of the person's shirt the brain will supply it it was blue otherwise they'd have on no shirt the brain supplies the details but when you see the mugshot later and find that the shirt was instead brown when you think back to what you saw you will remember brown this will be incorporated into the memory and you won't be able to tell the difference over time between what you actually remembered and what is a recall intrusion these are per below the surface of consciousness so real data and recall intrusions are indistinguishable so data changes with the telling the very act of trying to recall something is again not verbatim not words on a page but it is a reconstruction and if it's a reconstruction and the act of doing with the reconstruction itself alters the memory and then the new memory replaces the old memory via a process called reconsolidation what happens then to our memories this little photo reminds me of that telephone game that little elementary school kids play where you tell the first person a phrase and they whisper it and then they whisper it to the next person and by the time you get to the end of the line what comes out of that kid's mouth has really nothing to do with the original phrase they're totally different and so – it can be with our memories this is really important because when you think back about patients that you have treated or patients that you heard about or things that you have read you have got to take what you remember with a grain of salt it may not be completely an accurate representation of the truth then we have another problem what is memorable we all know intuitively that not everything is equally memorable I remember my wedding day I remember where I was on 9/11 I cannot remember what I wore to work last Tuesday it wasn't really all that long ago there are a lot of things that make things memorable and other things less memorable what are those well frequent exposure is one you see something often the common cold you see it you get to know it frequent exposure makes things memorable vivid stories make things very memorable I just read on the plane here the book by a chip and Dan Heath called made to stick and they open that with the urban legend that almost everyone has heard the guy goes out for a drink meets a strange woman wakes up in a hotel room next in a bathtub of ice and his kidneys have been stolen everyone knows that urban legend even if you didn't know it before you know it now and when you leave this room you'd be able to retell it but you're not going to be able to retell all the details of my lecture and you're not going to be able to retell all the details of the other lectures here tonight because some things are vivid stories are really really memorable things that are emotionally charged everybody remembers their first death physicians will remember the patient that died in front of them the first time and probably many of the patience if a physician makes an error that causes grave harm to the patient that becomes seared in the forefront of your mind never forget it and it changes your practice in a way that may not really be evidence-based novelty very interesting right things that are neat or easy to remember in medicine we call them fastened Oma's right or zebras and then recent exposure so something that might be very uncommon but it has happened recently will come more readily to mind so while we're talking about what makes things memorable let's revisit the first slide we are supposed to get a bunch of experiences personal experience vicarious experience and theoretical experience and it's supposed to come out and provide us with expertise that's supposed to come readily to mind but what really comes readily to mind are the versions of these things that are common recent vivid emotionally-charged a novel and this is a process called loosely availability bias recency bias is actually its own thing but in general I'm using this to describe the features of things that we learn about an experience that come readily to mind so to recap most expert thinking is non thinking it's type 1 thinking just like we did with the Cardinal what comes right aly to mind a cardinal are there other Redbirds out there probably oh it comes most readily to mind is the Cardinal our memories are not perfect and our experiences are not equally memorable so what are we to do here we know that the problem is occurring up here where we had saved as a pattern recognized yes and what we recognize are things that are memorable so I'm going to point out two additional arrows that I added to this schema from last time the first is the blue arrow not the one I've circled there but the blue arrow that goes from type two analytical up to intuitive this is when you have so many choices that you give up and say I'm just gonna go with my gut I I can't think about this anymore that might be how you chose your medical school in a big old spreadsheet of all the pros and cons and finally I just said you know I liked it at this one place better that's intuitive thinking we can do the same thing we can say I know it's a cardinal 100% I'm sure of it but let me just stop and do some investigation and see if there might be some other Redbirds and that's what I'm gonna give you three strategies now briefly three strategies to pull yourself out of intuitive thinking which is the experts primary way of thinking and double-check just double check the rule of three couldn't be more simple this is the idea that you should always consider three diagnoses to avoid premature closure that means we don't take the first thing that comes to mind that matches all the data we say let me consider three things and not only should I consider them but let me seek disconfirming evidence to rule them out this goes against our human nature tendencies when I get out of my house in the morning I see a card that is the make and model of my car or the color of my car and it's in my driveway so I say hey that's my car I don't come out of my house and say how can I prove this is not my car but that's what I'm asking you to do with the diagnosis you feel very sure about how can I prove do I have any evidence to suggest I'm wrong just consider it even when it seems obvious and expected like my car in my driveway this can be applied to therapy as well if you're giving a therapy if you're giving a vasopressor for example and then you're giving a second dose on that third dose you may want to say to yourself hey is this the appropriate treatment and perhaps more importantly do I fully understand the cause of what I am treating so the rule of three will help you to stop making your snap judgments and give consideration to a couple other things prospective hindsight is a strategy adapted from the military you know after something's gone wrong everyone sits around in the root cause analysis and things seem so obvious you point to the red flags how could you have missed that this was so seemingly clear but in real life it's not clear as it's happening prospective hindsight asks us to stop in the middle of an event and say to ourselves when I find out later that I'm wrong right now what will people say I missed what will be those red obvious flags and look around and finally 10 seconds for 10 minutes Marcus Rahl and his colleagues came up with this concept they basically say that we act too quickly in emergencies and that more patients are harmed from our rash actions than from a delay in treatment this applies to emergencies so he says in an emergency the leader should summarize the data but with hold a diagnosis and solicit from the team what do you think this could be and what should we do about it and then assign roles and make a coherent plan to carry out over the next 10 minutes so take 10 seconds or 15 seconds to plan for the next couple of minutes instead of acting rashly most mistakes are thinking mistakes when diagnostic errors occur and patient harm occurs someone has made a thinking mistake it's not because they've not heard of the right diagnosis it's not because the treatment is so exotic they didn't know to do it is because they made the wrong decision on that type one intuitive judgment where they recognized a pattern and they turned out to be wrong in this little brain image you can see that there's a lot of things that can influence us being wrong but specifically we spoke about memory shifting and about availability bias there are more on the other side we talked about rule of three prospective hindsight and 10 for 10 and there are more and I've talked about them on my blog I want these strategies to become your habits they have to be your habit even when you know absolutely that you are right you've got to be doing it when you're right why because like Katherine Schultz said in her book and in her TED talk being wrong feels the same as being right so if you're doing this when you're certain that you're right and you're doing it every time that you are absolutely right you'll also be doing it when you find out later that you are wrong we are what we repeatedly do Aristotle says so in medicine excellence is not an act but a habit thank you

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