Dr Andrew Cooke

Emergency Department Management Conference 2014

Tuesday 29 July 2014

Dr Andrew Cooke

MBBS (Hons); LLB (Hons); LLM (Hons) (Cantab)

Emergency Medicine Advanced Trainee, St George Hospital

Board Member, Clinical Excellence Commission, NSW Health

Board Member, Agency for Clinical Innovation, NSW Health

“YOU REMEMBER THAT PATIENT YOU SAW

LAST NIGHT…”

http://www.wimp.com/awarenesstest/

Aims: ◦ Overview on misdiagnosis

What we know about misdiagnosis in the ED & liability

◦ The patient safety response to misdiagnosis

Understanding thinking

◦ Has this influenced the standard of care in Australia

An unexpected consequence

◦ Case examples

◦ So what?

Using the commonly accepted turn -

around time of 72 hrs, the incidence

of patients who make an

unscheduled return visits to the ED

is between 3 – 10% Martin Gill C et al. Risk factors for 72 hour admission to ED. Amer J Emerg Med 2004 22(6): 448 – 53

Gabayan et al. Factors associated with short term bounce back admissions after emergency department discharge. Ann

Emerg Med 2013 62 (2): 136 – 144

Robinson K and Lam B. Early emergency department representations. Emerg Med Australas 2013 25(2): 140 – 6.

System (18%)

Environment (unique to the ED) (10%)

Patient related (50-53%)

Doctor/Healthcare provider (15 – 25%) ◦ Of which diagnostic error and misdiagnosis is the major cause

Doctor/health care provider ◦ Diagnostic error by an MO in up to 20% of cases was identified as the reason

for the unexpected return (see Pierce JM et al. ‗Bounces‘: an analysis of short – term return visits to the public hospital emergency department. Ann Emerg Med 1990; 19: 752 – 7)

◦ Incidence of unexpected return due to a serious medical error is between 18 – 35% (see Nunez S et al. Unscheduled returns to the emergency department: an outcome of medical errors? Qual Saf Health Care 2006. 15(2): 102 - 8)

◦ Of the medical errors made, a misdiagnosis (either a failure to diagnose or an

incorrect diagnosis) represents over 40% (see Brown et al 2010)

◦ Misdiagnosis related claims >50% of claims associated with emergency medicine (see Australia‘s medical indemnity claims 2011 – 2012, AIHW)

CEC Clincal Focus Report – Diagnostic Tests 2011

“Review of malpractice claims have a morbid attraction that is similar to gazing at crash scenes. Both provide the observer with a vicarious, cathartic experience…”

“Both hindsight and outcome bias have been convincingly demonstrated in a number of fields, including medicine. These biases are powerful and insidious and make it hard for historical analysis (such as RCA or closed claim reviews) to yield useful understandings of accidents or adverse events…Thus reviewers who know the outcome of a case glibly judge cues to the correct diagnosis as being much more evident than they actually where and routinely overestimate the probability of the observed outcome.”

“We need to better understand practitioners in the „wild.‟”

Wears RL and Nemeth P. Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures Ann Emerg Med 2007 49(2) at 206

◦ Overview on misdiagnosis

What we know about misdiagnosis in the ED and liability

◦ Patient safety response to misdiagnosis

Beyond the rhetoric

◦ Has this influenced the standard of care in Australia?

An unexpected consequence

◦ Case examples

◦ So what?

How do we think about diagnosis? ◦ Dual Process Theory

System 1 (intuitive, heuristics) vs System 2 (rational and logical)

See for example Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning Adv in Health Sci Educ 2009; 14:27–35 (2009)

◦ Metacognition Alive to biases and heuristics and understand how they

operate in our decision and diagnosis making processes - cognitive interventions

See for example Graber M. The incidence of diagnostic error in medicine BMJ Qual Saf 2013; 22: ii21-ii27.

◦ Overview on misdiagnosis

What we know about misdiagnosis in the ED and liability

◦ Patient safety response to misdiagnosis

Beyond the rhetoric

◦ Has this influenced the standard of care in Australia

An unexpected consequence

◦ Case examples

◦ So what?

System 2 thinking (logical, analytical, reasonable) and the „standard of care.‟

To what extent are cognitive reasoning processes taken into account by the Courts in determining whether what was done was „reasonable‟?

How has (and will?) the growing pressure of literature on cognitive reasoning and the processes influence and inform the standard of care expectations?

s 5O Standard of care for professionals

(1) A person practising a profession (“a professional”) does not incur a liability in negligence arising from the provision of a professional service if it is established that the professional acted in a manner that (at the time the service was provided) was widely accepted in Australia by peer professional opinion as competent professional practice. (2) However, peer professional opinion cannot be relied on for the purposes of this section if the court considered that the opinion is irrational. (3) The fact that there are differing peer professional opinions widely accepted in Australia concerning a matter does not prevent any one or more (or all) of those opinions being relied on for the purposes of this section. (4) Peer professional opinion does not have to be universally accepted to be considered widely accepted.

If the [defendant] acted in a manner that was widely accepted by peer professional opinion as competent professional practice then subject to rationality that professional practice sets the standard of care. (Court of Appeal in Dobler v Kenneth Halverson [2007] NSWCA 335 per Giles JA)

―Although expert evidence produced

that supported GP’s approach into

investigation and diagnosis it was

irrational because it lacked logical competence..”

What is (ir)rational (or in Victoria, unreasonable)?

◦ Irrational by what reference point? Decisions made on incomplete information, changing conditions and

uncertainty (this is ED medicine) are probably irrational. The ED doctor (busy, multiple patients, needing to keep the department

moving..) is probably irrational. Because the decision made turned on heuristics and implicit biases (not

a system 2 thought process) is this prima facie irrational?

◦ Or as in Bolitho: “if it can be demonstrated that the professional conduct is not capable

of withstanding logical analysis, the judge is entitled to hold that the body of opinion is not reasonable or responsible…” (see Bolitho [1998] 1 AC 232, 241–2)

◦ Logical analysis (System 2) vs judgment/instinct (System 1)

Clinical decision rules/guidelines/provision of decision support at the point of care

◦ Overview on misdiagnosis

What we know about misdiagnosis in the ED & liability

◦ Patient safety response to misdiagnosis

Beyond the rhetoric

◦ Has this nfluenced the standard of care in Australia

An unexpected consequence

◦ Case examples

◦ So what?

58 year old man presents to a tertiary ED

Abdominal pain and vomiting.

Category 2 for pain and tachycardia (130): ―This is like my renal colic Doc”. Phx HTN and

smoker

ECG SR no ischaemic changes; U/A – moderate blood; HTN 150/80.

High analgesic requirement in ED but eventually settles.

Remains hypertensive (150 – 160 systolic) and discharged home.

Renal colic. No US attempted.

Local protocol recommends CT KUB to confirm stone/exclude other pathologies ie (a

leaking abdominal aneurysm) if: over 50 or diagnostic uncertainty.

Four hours later, unexpected return to ED after a collapse at home. Dies from massive

haemorrhage and shock secondary to ruptured abdominal aortic aneurysm.

NZ Health & Disability Commissioner – ED Registrar (Dr C) and

Otago District Health Board (2009)

System 1 vs System 2

System 1 (quick, pattern recognition, confirmation by a single positive test) vs System 2

(logical, stepwise approach; any features that don‘t fit difficult u/s exam; persistent

hypertension)

Based on simple pattern recognition; an intuitive response (System 1) vs logical (System 2)

(illogical to ignore a guideline?)

Metacognition

Multiple factors

Framing effect (―this is like my renal colic‖)

Anchoring bias (―UA was positive‖), choose to ignore other high risk factors for a vascular catastrophe

Cognitive overload (registrar was exhausted)

Availability bias (renal colic is a familiar dx)

―…was working alone and with an unsafe

workload. He was tired and hungry and did

not have an adequate opportunity to

consider this case in a measured manner..‖

(No System 2)

―…Senior Emergency Physicians use

judgement and experience to make a

diagnosis and reduce needless

investigations and consultation, regardless

of guidelines. Registrars strive to emulate

this pattern and must make independent

decisions in order to progress…‖ (System 1

expressly favoured)

A 37 year old man. Presents to ED. Triage category 4 (PR 130). Looks well.

Diarrhea, sore throat, headache, cough and difficulty breathing.

Phx asthma and frequent alcohol consumption. Smoker.

Moderate dehydration and likely viral bronchitis. Tx.

2hrs later vitals are recorded and abnormal, but looks well. DC‘d.

Tachycardia? not unusual due to a combination of his acute illness, use of ventolin

(a bronchodilator) and moderate dehydration.

Presents to GP next day worse: ―patient has bronchitis….viral illness‖, notes a

persistent tachycardia (PR 113). Differential of cardiomyopathy.

Two further consultations with GP and investigations. Referral made to a

cardiologist (day 5 of illness) .

Suffers asystolic arrest due to cardiomyopathy.

McKay v McPherson [2010] VCC 585

Both doctors (ED and GP) found negligent and in contravention of Wrongs Act (Vic)

for not acting on abnormal vital signs (and not referring earlier). Note taking and

documentation.

System 1 vs System 2

◦ Other available alternatives to explain the patients persistent tachycardia and

low oxygen sats (System 1: ―Looked well..‖). Documentation lacked any

reflection of cognitive interrogation

◦ The wrong option is to summarily dismiss an abnormal finding, without

noting that it has been identified and how its presence factors into the

decision making process (System 2)

◦ ―…the defendant adhered to a provisional diagnosis even when symptoms

persisted which should have made the doctor reconsider his or her initial

diagnosis‖ — O’Shea v Sullivan (1994) Aust Torts Reports 81-273

Metacognition

◦ Diagnostic momentum – the biggest impediment is a prior diagnosis

A 52 year old man. Past history of possible drug use and depression. Other past hx includes diverticulitis. Presents to ED with abdominal pain and

constipation. ED doctor notes record “unkempt appearance,

underweight and frequent requests for pain relief..” [in the setting of known? drug user]

Abdominal xray showed some faecal loading. Surgical review, treated with partial relief with an

enema and discharged from ED. Represents the next day and dies from a

perforated diverticulitis

NSW Coroner’s Inquest into the death of Michael Sutherland

(2011)

System 1 vs System 2

◦ Coroner found that the diagnosis of constipation brought about by drug use and

now drug seeking behaviour was fundamentally flawed. ―…the [ED Doctor] had

stereotyped [the patient] as a substance abuser…‖ and ―..led her prematurely

close her mind to other alternatives…‖ (a complete failure of System 1)

◦ Pervading stereotype of the patient informed all decisions going forward.

Metacognition

◦ Express reference to cognitive pyschology around error

◦ ―Availabilty heuristic‖ (constipation and drug use an easy diagnosis to make) and

―premature closure‖

“Despite the inherent difficulties in developing clinicians‟ awareness about their own thinking in the

clinical setting…the principles of metacognition and awareness of cognitive error are built into the practice of differential diagnosis

and thus an integral part of medical practice…” (System 2)

Inquest into death of Israelu Pele – NSW Coroners (May 2010)

Recognize some familiar high risk features (non specific – complaints; patients with abnormal vital signs..)

A lot of what we do in ED expressly turns on System 1 thinking (the patient looked well; there was a clear pattern to the diagnosis etc) ◦ For all patients we need a System 2 “check” point

The law has quickly adopted the language and psychology of decision making in its articulations of: ◦ Standards of professional competence (ie medical

board/tribunal) ◦ Standards of practice (ie Coroners); and ◦ Articulations of the “standard of care” especially in

relation to “rationality‟ (ie Courts). ◦ Cognitive expectations

In few cases there has been an express adoption

of dual process theory informing the standard as articulated by the Courts (Dobler and McKay).

◦ Overview on misdiagnosis

What we know about misdiagnosis in the ED and liability

◦ Patient safety response to misdiagnosis

Beyond the rhetoric

◦ Has this influenced the standard of care in Australia?

An unexpected consequence

◦ Case examples

◦ So what?

Will understanding how we think make a difference?

◦ Not yet clear –need quantitative data about decisions at the point of care to

support the narrative

◦ Need ―ownership‖ of the problem

◦ Work of the CEC – Understanding and reducing diagnostic error in medicine – a

pilot program (2014)

Medico-legal fraternity

◦ Medical indemnity – what is expected? Decision support? Decision training?

◦ Experts – quality of the decision vs quality of the decision making; role of

cognitive psychology and understanding where we are in the decision making

pathway?

◦ Litigators – will these considerations influence the standard of care - ? Directly

(expected that doctors should be more aware of cognitive errors/decision

making models as part of their ‗duty of care‘); Indirectly? Peer professional

defence and irrationality (? Logical; reasonable; system 2 theories)

How can we “own” the problem of misdiagnosis? ◦ Triage

◦ How well do we interrogate our own diagnostic making decisions in the ED?

◦ How well do we document (and audit) the documentation of these processes? How well do we show our reasoning?

◦ How well to do we teach this?

◦ How well have we studied this? More than the narrative

AIMS CONCLUSIONS

What we know about misdiagnosis in

the ED?

Big deal in terms of liability

What is the patient safety response?

Growing pressure of literature telling us

that dual process and metacognition is

key

This is already influencing articulations

around the standard of care

Decision quality versus decision content

This is already informing the standard

So what? An opportunity…

Dr Andrew Cooke

Emergency Department Management Conference 2014

Tuesday 29 July 2014

Dr Andrew Cooke

MBBS (Hons); LLB (Hons); LLM (Hons) (Cantab)

Emergency Medicine Registrar & Advanced Trainee, St George Hospital

Board Member, Clinical Excellence Commission, NSW Health

Board Member, Agency for Clinical Innovation, NSW Health