Being Biased Against Being Biased (Part Two): Rational Road
By George Barnes MS, CCC-SLP, BCS-S
Edited by Allie Mataras MA, CCC-SLP, CBIS
Missed Part One? Check it out here.
When to Slow Down your Thinking
It’s OK to think fast. If we didn’t have that capability, it would take us an hour and half to choose what to eat for breakfast as we weighed all the pros and cons of hot vs cold cereal. Going with our gut is helpful. Especially in emergencies. What’s important is to know when to slow down and pull out that system two thinking cap. Maybe it’s when making a final decision on a diet consistency. Determining whether or not to make a patient NPO. Or weighing different risk factors of pneumonia and figuring out how to best manage that risk. When the stakes are high and the question is complex (which it often is in dysphagia management), slow and steady wins the race.
Be mindful- sounds spiritual and fluffy, but it’s actually grounded in evidence. Being mindful helps us avoid running on autopilot, ruminating on prior cases, and letting our emotions get in the way of a rational decision making process. It will help us get rid of distractions and focus on the important clinical information. In short, being mindful will help us combat bias. It’s extremely easy to get caught up in the flow of the day, letting the chaos take us away into a sleep-like daze. Fighting this needs to be intentional and requires changing environmental cues (i.e., a reminder sytsem or checklists), paying attention to our own needs (i.e., fatigue, sleepiness, hunger, thirst, or frustration), or maybe even adding in some daily meditation if you’re into that sort of thing.
Practice makes progress
Consistently getting involved in the most challenging of cases will improve your pattern recognition for the most important clinical information. The more patients we see, the easier it will be to spot the salient features that will lead to an accurate diagnosis and an effective treatment plan. If your schedule allows it, pick up additional PRN work, take on new challenging cases, and think about starting a case study review group with your colleagues to reflect and build on your weaknesses. The more you see, the better you get.
Avoid burnout and fatigue
This topic deserves a whole separate blog, but in the spirit of staying well-rested and healthy, I’ll keep it short. The takeaway here is that burnout and fatigue are well documented in healthcare and have a negative impact on patient outcomes. Making sure we are maintaining a healthy lifestyle with plenty of rest is imperative not only for our own well-being, but for our patients’ as well. That 30 patient caseload with a 90% productivity requirement? Not OK. I know we all have to get a paycheck, but you want to live long enough to actually spend it. If you’re a masochist and enjoy a fast and furious schedule then shift your perspective to the potential negative impact this could have on your patients.
The following tips have been derived from a previous post called Digging for Dysphagia with some new additions.
Have a system
Approach every patient the same way every time so that we don’t miss any key information. Review your chart the same way, perform your oral motor exam the same way, and yes, conduct your MBSS and FEES exams the same way (preferably based on a standardized approach). Every time. No exceptions. OK?! Sorry, it’s just that it’s important to stick to a routine so that we don’t veer off course when our bias kicks in… “He has pneumonia? Must be aspiration...NPO.” “This person has been NPO for 2 years, there’s no point in re-checking now!” Or on the other side of the equation… “She came in on a regular diet? Must be fine, no reason to check further.” Bias can work both ways- we can be biased for or against dysphagia. It’s the being biased against being the biased thing that we are striving for. By doing everything every time with everyONE in a strict procedure-like routine supported by evidenced based practice, you are less likely to let your biases get the best of you.
Here is a six step process I use to make sure I don’t miss any of the many moving parts in dysphagia management:
Step 1: Identify and define the problem: This is the most important step as you don’t want to solve the wrong problem, miss the bigger picture, or fail to understand the problem in the first place. Pro tip: Always define the problem by its root cause and not by its symptoms. This will help you keep your eye on the big picture. To do this effectively, we must...
Gather data: Chart review, clinical evaluation, and discussions
Generate hypothesis based on the data: “This patient has dysphagia s/p brainstem CVA I tell you!”
Hypothesis testing (e.g. instrumental study)
Reflection/Explanation: Talk to the patient and the IDT about your hypothesis. “This is what I’m thinking and this is why I’m thinking it. Am I missing anything?”
Diagnosis: “This patient DOES have dysphagia s/p brainstem CVA, I told you!”
Step 2: Identify all factors: May include risk factors, patient preferences, goals, and patient’s tolerance for risk.
Step 3: Assess the factors: Learn as much as you can about the factors and weigh them accordingly based on clinical knowledge and research. For aspiration pneumonia, for example, we may want to weigh certain risk factors like poor alertness, poor secretion management, and poor respiratory health as higher than other factors, such as age, mild confusion, or polypharmacy.
Step 4: Generate an approach: What will have the largest impact towards reaching the goal based on the weighted factors?
Step 5: Consider alternatives: People typically get stuck on one choice OR fall victim to constantly searching for other alternatives until the time and money spent searching outweighs the value added to the patient. Be creative and consider opportunity costs. Also, don’t forget you can use multiple approaches at once if feasible.
Step 6: Adjust as needed: Medical conditions are complex often involving multiple moving parts. Don’t assume you’ve made the right decision. Make sure you did. Follow-up regularly to see how your decision has impacted the patient in terms of their medical status and quality of life so you can make any necessary adjustments to keep them on course.
Cognitive Forcing
This is a fancy way of saying “chickety check yourself before you wreck yourself.” Have a checklist. Make policies and procedures with clear steps for complex tasks. Incorporate decision trees and flowcharts. And take the time to train yourself and your colleagues in these steps. Monitor each other over time with regular training so nobody falls back into bad habits. Atul Gawande says in his incredibly simple yet profound, The Checklist Manifesto, “We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.” There is plenty of excitement in healthcare that we don’t have to create more of it by missing vital steps in our system. Force yourself into a system two process by planning it out first.
Look at the whole picture
Do a thorough chart review looking at everything from vitals to imaging to lab work and DO NOT forget the progress notes (It can be a lot to mine through, but you’re bound to find little golden nuggets of information that you would have missed otherwise). If you approach this in a systematic way (see above in case you forgot about effective systems), not only will you be more likely not to miss anything important, but you’ll move through everything faster once it becomes routine.
The IDT are your best friends and essential when we are trying to see the big picture. You want to see the patient through multiple perspectives to fully grasp what’s been going on with the patient: The current trends, medical stability, and PO tolerance. It’s important to remember that there doesn’t always have to be a problem. You may find that the patient is stable and is having no significant difficulties, but that an evaluation is part of a stroke protocol. Or that the patient had confusion which has now resolved. Or that the baseline diet is simply unknown and the team wants to double-check with the expert (that’s you). Don’t dig for dysphagia where there isn’t any.
What question are we answering?
This is our north star. Why were you consulted for the evaluation in the first place? Talk to the doctor and find out what the concern is with the patient’s swallowing or if she is just trying to rule out another factor that could be leading to some sort of aerodigestive issue. Odynophagia? Increased coughing? OR increased risk due to comorbidities and nothing to do with physiology? The only way we can get this information is by going directly to the source: The MD who ordered the evaluation. Even more importantly, what questions and goals are we addressing for the patient? Thinking about our thinking is great, but thinking about being thoughtful is better. The patient and their wants/needs are the true north star in this show so make sure the doctor’s question and what the patient wants answered are aligned.
Challenge yourself and others
Audit each other, explain your thought processes and have somebody poke holes in your logic. Effective decision making isn’t something we have or we don’t have. It’s learned. It’s earned. Your brain is a muscle and the only way to build it is by stretching it and working it to levels that are out of your comfort zone.
Broaden your scope (and use one too)
Instead of jumping to conclusions, get grounded in evidence. This is to avoid a knee-jerk reaction... “The patient was coughing so it must be dysphagia.” A cough can be from any number of causes. Using this example, let’s zoom out and examine all possibilities: a cold, the flu, pneumonia, asthma, COPD, bronchitis, GERD, postnasal drip, fibrosis, heart failure, laryngitis, cancer, pulmonary embolism, tuberculosis, emphysema, sinusitis, etc. The list goes on. Seriously.
By assuming there is dysphagia we may jump to an intervention that may, in itself, cause negative effects (e.g. thickened liquids lead to reduced intake and changes in medication breakdown). So we better know FOR SURE if the patient has dysphagia before we start meddling. Even if a patient is coughing during intake, this does not confirm aspiration (I, myself have seen many patients coughing during a FEES with no penetration or aspiration). If dysphagia is suspected, get an instrumental study and quickly. Try not to make a decision at the bedside because you might be doing more harm than good and nobody has that as a career goal.
Fight Your Bias
Bias will always be a part of us. Whether we like it or not. It’s like that memory of the awkward time you went to a costume party as Big Bird, only to realize upon your arrival that it wasn’t a costume party (just me?). It’s not going anywhere so we might as well learn to live with it. In fact, just being mindful of bias is an enormous step in the right direction. You’ll quickly learn how much of a zombie you’ve been throughout your career, making decisions based on faulty research, incorrect logic, or without sufficient evidence. It takes dedication, hard work, and persistence to fight our biases, but it can be done. And when your patient is safely having their favorite grilled cheese sandwich for the first time in weeks, they’ll thank you for it.
