Content area
Abstract
The study seeks to understand and reduce fixation error (the process of sticking to a single presumed diagnosis despite mounting cues one is on the wrong track) by anesthesiology residents during simulated acute medical crises. Transcending fixation error and managing the crisis requires a transition from a routine, or “single-loop” operating mode, where the underlying situation is assumed to be known, to a “double-loop” error-correcting mode, that questions one's view of the situation. The necessary shift in cognitive framing is not natural; it requires intelligent effort. Drawing on theories of reflective practice and organizational learning the study explores the behavioral, and cognitive/emotional patterns that foster fixation error or help one transcend it. I conceptualized fixation as being the result (1) self-sealing (vs. self-correcting) conversational and diagnostic tactics that block out corrective information and (2) a failure to balance exploration of new possibilities and exploitation existing certainties.
Part 1 develops and implements a fixation-reduction technique and a training program to teach it in collaboration with anesthesia faculty at the Harvard Medical School. Part 2 tests the power of the technique and the theoretical model underlying it. Part 3 revises the theory underlying Part 2 and some of its measures and uses qualitative and quantitative analysis to test the effectiveness of the revised theory. The qualitative analysis in Part 3 develops a typology of different problem-solving modes including “Fixation” and “Diagnostic Vagabonding” (in which the clinician jumps from diagnosis to diagnosis without treating or testing any thoroughly) and uses the typology to highlight dynamics of problem-solving failure and success in the OR. This study highlights the fact that failures to handle OR crises effectively are related not to weaknesses in technical knowledge but rather to limits in reflection, communication, and “metacognition” skills that allow doctors to detect and correct their errors on the fly. It lends support to the idea that effective crisis management in time-constrained, high-stakes settings requires an integration of single- and double-loop problem-solving modes.