Distracted By DEATH

Distracted by DEATH
Dangerous Minds

This content focuses on cognitive error and how to combat it. 

The Traps

The “Traps” are conditions that set a person up for cognitive error.

  • Faulty Knowledge

    Faulty medical knowledge is an obvious trap for making a cognitive error. You have to know your stuff.

  • Emotions

    Emotions are part of being human, however they can also be a trap for making a cognitive error. 

    All decisions have an emotional value attached. Reasoning will provide you with a list of options but…Emotion will influence your final decision.  

    We may treat a patient differently because of our emotions (positive or negative)

    Negative Emotions can lead to the patient getting…

    • Less care
    • Less time
    • Less anesthesia

    Positive emotions can lead to the patient getting inappropriate treatment. We may avoid (indicated) painful/expensive procedures and/or minimize the likelihood of important (serious) diagnoses. 

    Common situations that trigger emotions are when dealing with

    • Demanding patients
    • Patients who question your decisions
    • Patients with particular chief complaints
    • Patients with differences in moral judgements (lifestyle differences)
    • Patients in certain demographics  (psychiatric, homeless, drug seeker)
    • Patients who you don’t think need to be seen (common in emergency departments, for example the patient that comes in for a non-emergency because it’s convenient) 

  • Personal Agenda’s

    Having anything but the patient’s best interest in mind…can be a trap for cognitive error. 

    This includes…

    • Politics
    • Personal life
    • Money
    • Wanting to go home
    • Defensive medicine

  • Mental & Physical Wellness

    Threats to your wellness can be a cognitive traps. 

    • Fatigue
    • Hunger
    • Illness
    • Personal Issues
    • Disabablities 
    • Mental Health

  • Thought Process

    How past experience affects thought process can be a cognitive trap

     Type I thinking vs Type II thinking

    Type I (Intuitive)

    • Processes are very fast
    • Used by experts most of the time
    • Pattern Recognition

    Type 2 (Rational)

    • Processes are slower
    • More reliable
    • Focus more on hypothesis and deductive clinical reasoning
    • Doing this enough turns thinking to type 1

    We all start by doing Type II thinking (this is what medical students do), but in training we are encouraged to do Type 1 thinking. We also naturally are driven to do type I thinking. 

    The reason we naturally want to do type I thinking is explained by the “Cognitive Miser Function”. The theory suggests that humans, valuing their mental processing resources, find different ways to save time and effort when negotiating the social world. 

    The problem is that most errors occur when doing Type I thinking. People misinterpret the patterns. 

  • Cognitive Load

    Cognitive Load traps can be grouped into 2 groups…Threats to Thought & Tons of Thought

    Thought disruptors

    • Multiple interruptions
    • Care transitions
    • Time pressure

    Too much to think about

    • Multiple patients
    • Limited information
    • Diagnostic uncertainty
    • High decision density

     

     

     

     

The Errors

Patient Trait & Presentation Errors

  • Attribution Error

    Tendency is to fit history, physical findings and lab studies into a preset conception about that person (stereotypes)

    Common examples include

    • LGBT
    • Druggie
    • Race
    • Homeless

     

  • Psych-Out Error

    There is a tendency to under asses and under treat psychiatric patients. 

    • A clue is hearing the statement “That patient is just crazy”
    • This is a type of attribution error, it is so common it gets a special name.

     

  • Yin-Yang Out Error

    The patient has already had a complete workup (worked up the Yin-Yang)…so we do go in with open mind. 

    Tendency to begin with a defeatist attitude

    Remember….

    • The diagnosis may be evident now…
    • Maybe the smoke has cleared
    • This may be a new problem

  • Triage Cueing

     Assuming that a patient can’t be sicker than their triage level. 

    Physician falls into trap of believing the triage level.

  • Availability Error

    To judge things as being more likely just because they readily come to mind.

    We are strongly influenced by dramatic or unusual cases that are prominent in our memory and easily recalled, and thus “available” when we consider a new patient’s problem. 

    The error is to judge things as being more likely just because they readily come to mind (recall). 

    Cases that are unusual, dramatic, and recent are those that are easiest to recall.

     

Inheriting Thinking Errors

  • Diagnostic Momentum

    Passing a diagnosis from provider to provider.

    Once the patient is given a diagnosis, it becomes difficult to remove. The diagnosis is then passed from provider, to provider, to provider…

    Example: COPD remains on chart even though patient has never been officially worked up for this

    • So all providers build a mental picture that the patient has COPD
    • Can come from Triage Cueing Error 

    Another similar version is Complaint Momentum, this is where the Chief Complaint on the chart get’s carried with patient during the visit.  This is common in emergency departments. 

  • Cognitive Transfer Error

    Passing Biases from provider to provider. 

    Here clinicians “pass off” their BIASES when transferring the care of a patient to someone else. 

    Especially likely to occur during shift change and sign-out rounds

    This not passing diagnosis (like diagnostic momentum), it is passing BIASES from person to person. 

     

Over Attachment Errors

  • Sunk Costs

    The more clinicians invest in a particular diagnosis, the less likely they are to consider alternatives. 

    The clinician often continues to invest resources into a previously selected action or plan. 

    Even after the plan has proven to be the suboptimal option.

    Example: A physician doing a sepsis study, classifies her patient as having sepsis and does not consider thyroid storm, even after all the test results are not consistent with sepsis.

  • Anchoring

    First impression or one piece of evidence exerts undue influence in the diagnostic process. 

    The tendency to lock on to a decision too early in the diagnostic process. 

    This is a problem with misuse of likely hood ratio’s.

     

  • Conformation Error

    Involves ignoring or rationalizing contradictory data to make the pieces of the puzzle fit neatly into the presumed picture.

    An unusual complaint or laboratory finding is dismissed in our minds as an “outlier.” When it should actually raise a red flag, indicating that our presumption may be incorrect

    This is a very important error that is often caused by the other cognitive errors. 

  • Pre-mature Closure

    Accepting Diagnosis before it has been FULLY VERIFIED

    • The tendency to pre-maturely close the decision making process. The problem is when we think a diagnosis is made, the thinking stops (like search satisfaction, except in this case a real diagnosis was not made)
    • This accounts for a high proportion of missed diagnoses
    • Remember: Look at the evidence that both supports and refutes the diagnosis and, if lacking, obtain appropriate evidence.

Failure to Consider Errors

  • Search Satisfaction

    Stopping search as soon as something is found or when search turns up nothing

    Dr. Stanley calls this a “Think again Error”

    This is when the search is called off as soon as something is found.

    It is also stopping the search if nothing is found.

    Are you looking in the right place?

  • Sutton’s slip

    Possibilities other than the obvious are not given sufficient consideration.

    The diagnostic strategy of going for the obvious is called Sutton’s Law

    The SLIP (cognitive error) occurs when possibilities other than the obvious are not given sufficient consideration i.e: Not considering a blood disorder in what looks like a simple obvious nosebleed. 

Estimation & Probability Errors

  • Playing the Odds

     Ruling out a diagnosis just because it is not probable  (unlikely)

    • e.g. headache/fever/bacterial meningitis

    Tendency: In equivocal/ambiguous presentations to opt for a benign diagnosis on the basis that it is significantly more likely than a serious one.

    • The Mimic Effect: The Signs & Symptoms of many common & benign diseases are mimicked by more serious and rare ones.

  • Vertical Probability Error

     Ruling in a diagnosis just because it is the most probable. 

    The tendency to think that the most probable diagnosis is correct. 

    The most probable diagnosis is NOT always correct.

  • Gamblers Fallacy

    Thinking that because last five pt’s had same dx, the 6th patient won’t have it (thinking your past history will influence what patient has)

  • Posterior Probability Error

    The likelihood of disease is unduly influenced by what has gone on before for a particular patient. 

    This is similar to Base-rate neglect

    • The tendency to ignore the true prevalence of a disease
    • Either inflating or reducing its base-rate
    • This distorts Bayesian reasoning
    • Can alter pre-test probability

    NOTE: In some cases, clinicians may (consciously or otherwise) deliberately inflate the likelihood of disease

    • Such as in the strategy of ‘‘rule out worst-case scenario’’ to avoid missing a rare but significant diagnosis

  • Prototype Error

     Only looking for prototypical manifestations of disease. 

    It can’t be a Duck, because it does not look like one

    Example: 

    • The aortic dissection that does not present with ripping tearing chest pain radiating to the back
    • The young female with chest pain who is having Unstable Angina

Tools for Combat

Distracted by D.e.a.t.h.

  • Distracted

    Before you think about “Distracted by D.E.A.T.H.” You should take some time to think about your own Risk Acceptance and your patient’s risk acceptance. What are you and your patient willing to risk?

    Distracted

    This aspect of the “Distracted by D.E.A.T.H.” focuses on the cognitive traps already discussed. You first need to know if their is distraction occurring. 

    You need to have Internal & External Awareness

    • You need to understand your level of hunger, fatigue, stress, distraction in personal life, and cognitive overload
    •  

  • D = Data

  • E = Emergent

  • A = Abbarency

  • T = Talk

  • H = Harm

Cardiovascular ICU Selective/Elective

Teaching Chief: Kartheek Nagappala MD

Description: Advanced Cardiovascular Critical Care rotation will allow residents to further develop their skills, knowledge and attitudes obtained during their previous rotations, specifically expanding on their critical knowledge to patients that are post cardiac surgery, major vascular surgery, and critically ill due to compromise of their cardiovascular system. The rotation will involve 21-22 12-hour shifts, similar to the EM core ICU experience. 

Availability: Generally available year-round and will occasionally share the experience with an Anesthesia co-rotator.

Scheduling: Schedule to be made by the rotator with final schedule approval by the teaching chief

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Community Emergency Medicine Elective

(PGY-3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Palliative Care Selective/Elective

Teaching Chief: Ryan Howard MD

Description: The Palliative Care Selective or Elective is a 2- or 4-week inpatient rotation designed to expose the rotator to all aspects of inpatient palliative care. Residents will work alongside the palliative director and/or the palliative fellow along with the interdisciplinary palliative team throughout the rotation. The goal is to provide either PGY2 or PGY3 residents with an immersive clinical experience to learn more about inpatient palliative services.

Availability: Generally year-round, those interested in applying to Palliative Fellowship get precedence on the rotation as space is limited

Scheduling: M-F, 8am-5pm, with call shifts if required/desired per Dr. Howard

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Intro and Advanced Pharmacology Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD and Savannah Lail PharmD

Description: A 2 or 4-week rotation where the resident works and learns alongside the ED pharmacists on assigned shifts. The Pharmacology rotation is designed to provide training concerning the application of pharmacology knowledge, pharmaceutics, drug information, medication safety, communication skills, critical thinking, pathophysiology, and therapeutics to the care of patients in an emergency department setting. The advanced rotation is for those who have already had the introductory Pharmacology rotation experience.

Availability: Generally year-round, but must contact PharmD teaching chief prior to choosing the rotation to ensure availability. 

Scheduling: Variable shifts, 10-shifts per rotation, to be assigned by PharmD teaching chief

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Pulmonary and Ventilator Management Selective/Elective

Teaching Chief: Leland Beggs MD

Description: This is a 4-week rotation based in the ICU, CVICU and ED. Residents will work side-by-side with designated respiratory therapists as well as core faculty physicians. The goal of this rotation is to focus solely on vent management and non-invasive ventilation techniques in patients with a wide variety of disease processes. Residents will be expected to manage vent settings for intubated patients in the ED, ICU and CVICU. Residents on service should gain an in-depth understanding of the events surrounding intubation, including strategies in pre oxygenation as well as the various drugs used for RSI and post intubation sedation. In addition, they will learn when to initiate, and how to manage non-invasive ventilation.

Availability: Generally year-round

Scheduling: M-F, 6am-4pm

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Radiology Selective/Elective

(Two-week experience) 

Teaching Chief: Ashkan Shahkarami MD

Description: The two-week Radiology rotation will provide the resident with an opportunity to learn normal and abnormal radiographic anatomy, recognize radiographic findings of common diseases, understand the indications for commonly ordered imaging studies, and learn the appropriate use of IR procedures. The goal of the rotation is to help the resident become competent in the use of imaging in the evaluation and treatment of disease.

Availability: Generally year-round, but must contact teaching chief before choosing the rotation to ensure availability

Scheduling: M-F, 8am-4pm, or as adjusted by the Radiology attending

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Wilderness Medicine Selective/Elective

Teaching Chief: Various

Description: The one-week wilderness medicine selective is offered twice a year at Kaweah Health, usually once in the Spring and once in the Fall/Winter. If not available during the allocated selective/elective block, previous residents have participated in 4-week experiences in Utah and Redding, CA. Experiences are variable and depend on the chosen course, so for this one touch base with Dr. Sukhija to see what is feasible both locally and away.

Availability: Highly variable, see description above

Scheduling: Highly variable

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Emergency Medicine Admin Selective/Elective

Teaching Chief: Kona Seng DO and Khoa Tu MD

Description: This is 2-4-week rotation in conjunction with the Department of Emergency Medicine Medical Director. The purpose of the ED Administration rotation is to provide an understanding of the administrative components of EM clinical services and operations. This will allow early exposure to ED administration to determine if the resident is interested in the administration and business of emergency medicine. The EM residents will attend all assigned meetings and participate in administrative projects. 

Availability: Generally year-round, will share the rotation with the PGY3 on their core admin rotation

Scheduling: M-F, 9-5pm, or as adjusted by the teaching chiefs

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Patient and Physician Advocacy and Street Medicine Selective/Elective

Teaching Chief: Kunal Sukhija MD, Omar Guzman MD, Lori Winston MD

Description: The Advocacy 2- or 4-week rotation is designed to be a self-directed customizable experience that will provide immersion into various aspects of physician and patient advocacy. The resident will be able to participate in local, state-wide, and national (schedule permitting) advocacy efforts while simultaneously learning about effective strategies to engage community leaders, legislators, and the local constituency. The rotation will offer experiences in both the legislative and community advocacy (the latter will be based in the Street Medicine program). 

Availability: Generally year-round, however certain months tend to be better given the yearly CMA, AMA, CalACEP, ACEP schedules. Touch base with Dr. Sukhija prior to choosing this elective in order to ensure you can get the individualized experience you desire.

Scheduling: Highly variable depending on advocacy events and meetings, Street Medicine tends to hold its events on Friday

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Performance and Quality Improvement (PI/QI) Selective/Elective

Teaching Chief: Chadi Kahwaji MD, PhD

Description: The Performance Improvement (PI)/Quality Improvement (QI) selective rotation will provide exposure to ongoing PI and QI efforts at KDHCD and provide opportunities for the PGY2 or PGY3 EM resident to become involved in PI/QI projects on an individual, departmental, or institutional level. The resident will join the Emergency Medicine PI director in the regular duties of chart review, M&M conference coordination and presentations, and committee meeting attendance as appropriate. It also offers time for the resident to work on their PI/QI project as part of residency graduation requirements. 

Availability: Generally year-round

Scheduling: Variable depending on meetings and current on-going projects

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Public Health Elective (PGY3 only)

(PGY3 only)

Teaching Chief: Karen Haught MD MPH, Tulare County Public Health Director

Description: This is a 4-week rotation with the Tulare Public Health Department designed to expose the rotator to all aspects of public health. Residents will work alongside the Tulare Public Health Director and/or the epidemiologist throughout the rotation. The goal is to provide PGY3 residents exposure to the role of the local public health department in the community. Residents will be expected to work at the Tulare Public Health Department and contribute to a community health project of the resident’s choice.

Availability: Generally year-round, though an interested resident should first contact Dr. Haught prior to selecting this experience (Dr. Sukhija will help you with contact information)

Scheduling: M-F, 9-5, though historically it’s been less than this as independence is given to work on the resident’s chosen project

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Research Selective/Elective

Teaching Chief: Chris Patty DNP, Director of Research

Description: The goal of the resident research rotation (2 or 4 weeks) is to improve the resident’s understanding of how new knowledge is created and translated into practice.  At the end of the rotation, the resident will present a deliverable which demonstrates ACGME competencies in knowledge development and translation. Many residents choose this rotation in order to work on their chosen Scholarly Activity as part of residency graduation requirements. 

Availability: Generally year-round, the resident must contact the director of research 4-weeks prior to the rotation in order to state deliverables and set up the rotational requirements.

Scheduling: Variable, generally self-directed independent work

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Simulation and Education Selective/Elective

Teaching Chief: Kim Sokol MD

Description: This is a 4-week rotation includes developing simulation scenarios, teaching simulation-based educational sessions, and assisting in daily operations in the simulation center. The rotation’s purpose is to develop skills associated with teaching. The rotation will provide an introduction to simulation with multiple adjuncts such as high and low-fidelity mannequins, task trainers, and the use of standardized patients.  A basic understanding of simulation-based education and debriefing will be taught along with basic principles associated with adult education. The resident must choose teaching shifts as their clinical experience.

Availability: Generally year-round

Scheduling: Variable, to be determined with the teaching chief prior to the rotation start date

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Teaching Elective with Dr. Stanley

(PGY3 only)

Teaching Chief: Michael Stanley DO

Description: This 4-week rotation is a highly-desired advanced elective rotation for PGY3 EM residents. It is intended only for those residents who are serious about improving their ability to teach AND lead. This rotation is as much about leadership as it is about teaching because both utilize the same skill sets. Residents will gain knowledge in effective communication techniques while learning about the underlying psychology of teaching, learning, and leadership.

Availability: Generally year-round

Scheduling: 12 10-hour shifts to be scheduled in accordance with Dr. Stanley’s clinical schedule, along with didactics (also to be scheduled with Dr. Stanley prior to the start date). If Dr. Stanley has less than 12 shifts, then the remainder can be completed with either Dr. Oldroyd, Dr. Sokol, or Dr. Alexeeva.

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Advanced Ultrasound Selective/Elective

Teaching Chief: John Hipskind MD

Description: This 4-week rotation is designed to augment the resident’s diagnostic (and therapeutic) skills in relation to the ultrasound, and to explore more advanced US modalities such as TEE. The resident will gain experience with nerve blocks, enhanced approaches to the core EM ultrasound studies, and explore novel ways to use the ultrasound in the ED setting. They will work alongside the teaching chief as well as the ultrasound fellows.

Scheduling: The expectation is to be scanning daily M-F, with weekends off. Due to PGY1 EM rotators and the popularity of this selective/elective, there may be many residents on rotation, and thus scheduling must be in conjunction with Mia Zavinovich and Dr. Hipskind prior to the start of the rotation. 

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International & Global Medicine Elective

(PGY3 only)

Teaching Chief: Various (depending on location)

Description: This is an opportunity to experience medicine across the care spectrum in a completely different cultural, social, and economic environment. From learning how to deliver sustainable care in critical access areas of the world, to experiencing Emergency Medicine as it is practiced elsewhere, the possibilities are endless. Previous residents have set up unique experiences in Uruguay, Thailand, Vietnam, and Tchad. Prior to thinking about an international elective the resident should consider travel, safety, health (vaccinations etc.), and financial concerns. Dr. Sukhija can help you guide you with strategies to set up an experience as each one is highly individual. 

Availability: Variable

Scheduling: Variable

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Patient Callbacks and PBLI form

Patient callback instuctions - complete 12/block when you are on the emergency medicine service

PBLI form - complete 4/year to reflect & self-evaluate your patient care

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