reducing bias in forensic & clinical decision-makinga working definition of confirmation bias...
TRANSCRIPT
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Reducingbiasinforensic&clinicaldecision-makingJOS EP H LOCK H A RT, P H D, A BP P
S ATY S ATYA - MURTI, MD, FA A N
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1.Lockhart:◦ Introduction◦ Definition andethical issues◦ Major Forensic Examples (asperDror)
2.Satya-Murti:◦ Ubiquity ofbias◦ Types ofBias
◦ Day-to-day,andclinicalexamples
3.Lockhart:Allegiance bias and“blind spot” bias
4.Satya-Murti:De-biasing research in clinical arenaOutline ofDe-Biasing techniques
5.Lockhart:Biasprevention ideasBiasand theexpertwitness
OOuuttlliinneeooffTThhiissPPrreesseennttaattiioonn
0:00 ~0:60
Q&A
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Shouldweworryaboutbiasindecision-making?
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Biasispervasive.Itaffectsevery,andall,aspectsoflife
DAYTODAY LIFE
HistoryWarfarePolitics
CLINICALMEDICINE
FORENSIC PRACTICE
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Anexamplefromledzeppelin
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AworkingdefinitionofconfirmationBias
“In[confirmation bias],oneselectively gathers,orgivesundueweightto,evidence thatsupports one'sposition whileneglecting togather,ordiscounting,evidence thatwouldtellagainst it.“
Nickerson,R.S.(1998).Confirmationbias:Aubiquitousphenomenoninmanyguises.ReviewofGeneralPsychology,2(2),175.
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EEtthhiiccaalliissssuueessffoorrffoorreennssiiccppssyycchhoollooggiissttss•Forensicpractitioners…
• striveforaccuracy,,fairness,andindependence.
• strivetotreatallparticipantsandweighalldata,opinions,andrivalhypothesesimpartially.
• strivetobeunbiasedandimpartial
SGFP, Guidelines 1.01and 1.02(APA, American Psychologist, January, 2013
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Ethicalissues
"Whenpsychiatristsfunctionasexpertsinthelegalprocess,theyshouldadheretotheprincipleofhonestyandshouldstriveforobjectivity.Althoughtheymayberetainedbyonepartytoacivilorcriminalmatter,psychiatristsshouldadheretotheseprincipleswhenconductingevaluations,applyingclinicaldatatolegalcriteria,andexpressingopinions."
Ethical Guidelines forthePractice ofForensic Psychiatry, 2005, www.aapl.org. Section IV
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EExxaammpplleessooffrreeaall--wwoorrllddffoorreennssiiccBBiiaass
ØFingerprintanalysisØDNAadmixtureØHairAnalysis
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ExamplesofBiasFingerprintanalysis
Whenintentionallyprovidedwithmisleadingcontextual information(e.g.,confession),fingerprintanalystschangedtheirpriorclassification80%ofthetime.
◦ Itiel E.Dror,DavidCharlton,&AilsaE.Péron.(2006).Contextualinformationrendersexpertsvulnerabletomakingerroneousidentifications.ForensicScienceInternational,156(1),74–78.
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ExamplesofBiasDNAAdmixture
17NorthAmericanexpertDNAexaminerswereaskedfortheirinterpretationofdatafromanadjudicatedcriminalcase,theyproducedinconsistent interpretations.Themajorityof'contextfree'expertsdisagreedwiththelaboratory'spre-trialconclusions,suggestingtheextraneouscontextofthecriminalcasemayhaveinfluencedtheinterpretationoftheDNAevidence
◦ SubjectivityandbiasinforensicDNAmixtureinterpretation.IEDror,GHampikian - Science&Justice,2011
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ExamplesofBiasForensicAnthropologyInassessmentofsex
31% oftheparticipants inthecontrolgroupconcludedthattheskeleton remainsweremale.
72% concludedthattheremainsweremaleinthegroupthatreceivedcontextualinformationthattheremainsweremale.
0%oftheparticipantsconcludedthattheremainsweremale intheparticipantgroupwherethecontextwasthattheremainswereofafemale.
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ExamplesofBiasHairAnalysis
Of28examinerswiththeFBILaboratory’smicroscopichaircomparisonunit,26overstatedforensicmatchesinwaysthatfavoredprosecutors inmorethan95percentofthe268trials
JURISPRUDENCE THE LAW, LAWYERS, AND THE COURT.
APRIL 22 2015 5:09 PM
Pseudoscience in the Witness BoxThe FBI faked an entire field of forensic science.By Dahlia Lithwick
The Washington Post reported that flawed forensic hair matches might have led to possibly hundreds ofwrongful convictions for rape, murder, and other violent crimes.
Photo by Victorburnside/Thinkstock
For more stories like this, like Slate on Facebook and follow us on Twitter.
The Washington Post published a story so horrifying this weekend that it wouldstop your breath: “The Justice Department and FBI have formally acknowledged thatnearly every examiner in an elite FBI forensic unit gave flawed testimony in almost all
THE FBI FAKED AN ENTIRE FIELD OF FORENSIC SCIENCE
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Biasispervasive.Itaffectsevery,andall,aspectsoflife
DAYTODAY LIFE
HistoryWarfarePolitics
CLINICALMEDICINE
FORENSIC PRACTICE
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Ex-British PM Tony Blair apologizes for Iraq War 'mistakes'. UUSSAATTOODDAAYY1100..2255..22001155
• "Icansay thatIapologize forthe factthattheintelligence wereceived waswrong because, eventhough he(-------) had used chemical weapons extensively againsthis own people, againstothers,theprogram intheform thatwethought itwasdid notexist inthewaythatwethought.”
HistoryWarfarePoliticsCLINICALME
FORENSICPRACTICE
DICINEHowdifficultitistoacknowledgeerror!
Illustrationofconfirmationandblindspotbiases.
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Normal pre-flight Flak pattern
• Statistical analysis reveals certainflak distributionpatterns(asabove)• Military analysts ask forextraarmoradded towhereholes clustered
• Wald challenges this andrecommends “considerjusttheopposite”– do notaddadditional protection tothose areas
Ifyou dothen itwillincrease your bomber loss ratio,notreduceit.
HistoryWarfare
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BBeeccaauussee
• You arelimiting your observations tothose planes thatsurvived thebombing raidand returnedhome
• Those thatplunged and werelostdid not return, because theywerehitin thenon-pattern areas.They weredestroyed
• Therefore, reinforce those areasnot shown inthereturning planes.
HistoryWarfare
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SurvivorshipBias
• Focusingonavailable evidence only• Ignoringmissing evidence• Notseeking contraryevidence
• Thosewhosurvived(returnedfromaraid).• Thosewhoprayedandsurvivedashipwreck• Eventhoughwepredictrisk,wedonotknowoutcomesafterrelease
DAYTO DAYLIFE
History
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History is so indifferently rich that a case for almost any conclusion from it can be made by a selection of instances.Durant and Durant, The Lessons of History, 1968
The human understanding when it has once adopted an opinion (either as being the received opinion or as being agreeable to itself) draws all things else to support and agree with it.Francis Bacon c.1620
Cognitiveerrorshavebeenwithusforalongtime.HistoryPolitics
In the last analysis, we see only what we are ready to see, what we have been taught to see. We eliminate and ignore everything that is not part of our prejudice.Charcot. C. 1870s
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SomeoftheCommonlyEncounteredBiasesinClinicalArena
• ConfirmationBias
• Retrospective(hindsight)Bias
• AllegianceBias
• IgnoringPrevalenceBias(Base-ratebias)
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IIlllluussttrraattiivveeccaasseess
Multiple biases
• 32yr F.Ltarm tingling,M.S. incousin,domesticstress,MRIsmallparietal T2hyperdense spot.IVPrednisolone.Better.
• 6wks later,tinglyhands,facial numbness,thickspeech.MRInochange.Dx:worseningMS.
• Air ambulancetotertiary center.
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AAnnootthheerriilllluussttrraattiivveeCCaasseeRReettrroossppeeccttiivvee BBiiaass
Setting50yrM.newonsetlowbackpainafewmonths.Active,healthy,overachiever.Normal exam.“ChoosingWisely” physiciandidnotimage.SymptomaticRx.Come forf/up.7days
Outcome
Potential Trial
Felt sowell, chosetowait. …………..
3wks lateracuteurinaryretention,catheterin,gaittroubleMultiple spinemets.
Defence:Followed guideline, Pt.failed tokeepf/up.No“redflags.”Whereispersonalresponsibility?Decision made under availableconditions.Outcome:yetunknown.
Guidelines acknowledgeexceptions,Physicianmusthaveimagedatfirstcontactinthecontextofa“nevercomplains” patient.Retrospectiveopinion,biasprone.Outcome:known
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AllegiancebiasAreForensicExpertsBiasedbytheSideThatRetainedThem?
(Murrie, Boccaccini, Guarnera, &Rufino, 2013)
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AAlllleeggiiaanncceebbiiaass•Subjectsbelieved theywerehiredbyeither
• defenseor• prosecution.
Examinedtworiskassessments: PCL-R and STATIC-99R
•Clearpatternofratingsemergedconsistentwithretainingside(uptod=.84)insomecases.
(Murrie, Boccaccini, Guarnera, &Rufino, 2013)
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Confidenceandaccuracy•Confidence andaccuracyinassessments ofshort-termriskspresented byforensicpsychiatricpatients (Desmarais, Nicholls, Read, &Brink, 2010)
•Clinical vs.statistical prediction: “Adjusting”estimates ofriskontheSTATIC-99basedonexternal factorstypicallymakes predictionLESSaccurate.• (DeClue, 2013); (Hanson, Helmus, &Harris, 2015)
•Confidence notclosely associated withaccuracyincardiacdiagnostic evaluation(Cavalcanti &Sibbald,2014).
•But,see(Douglas&Ogloff,2003)
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Wearefarbetteratrecognizingbiasinothers,ratherthanourselves
Neal, T.M.S.,&Brodsky, S.(n.d.).Forensic psychologists’ perceptions ofbias and potential correction strategies inforensicmentalhealth evaluations. Psychology, Public Policy, and Law.
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TThhee““BBlliinnddSSppoott””BBiiaass
Neal,T.M.S.,&Brodsky,S.(n.d.).Forensicpsychologists’perceptionsofbiasandpotentialcorrectionstrategiesinforensicmentalhealthevaluations.Psychology,PublicPolicy,andLaw.
ü Expertsweresurveyed,andfound:
ü Mostrecognizedbiasinotherexperts,butbelievedtheyandtheircolleagueswereunbiased.
v Expertsusedmanyapproachestoavoidbias,butmosthadbeenshowntobeineffective,including:
v Introspectionofpersonalbiases
v Reflection oncase
v Loyaltytodoinga“goodjob”
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Base-ratebias
Empirical evidence thatdisease prevalencemayaffecttheperformanceofdiagnostic tests withanimplicit threshold:across-sectional study.
Willis, B.H.BMJOpen, 2(1), (2012).
Walters, Kroner, DeMatteo, &Locklair, 2014
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Whatnext?
• Isbiasinevitable and ubiquitous?• Isitanormal operating characteristic of ourbrains?
• Isitevenpossibletoescapebias?
• We cancertainly aspire• ForAwareness thatbias exists in usand others, and• ToMinimize bias
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WhatisdebiasingDoesitwork
Will itworkinallbias inducingsituationsWhatistheexperience sofarinclinicalcare
Will itworkinforensicarena
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DDeebbiiaassiinngg eevviiddeennccee rreevviieewwExperiment orReview Method Findings Suggestions orConclusions
Lichtenfiled2009.Narrative,experientialessay.Emphasis:conf.biasanddebiasingmethods.
Extensive cataloguingof cognitivebiases Paucityof research andmixedevidenceoneff icacyof debiasing.
Graber2012Narrativereviewof141articlesoninterventionstoreducediagnosticerrors Lack real-worldsituations. Afewhelpfulwithtrainees.Fieldisimmature.
Sherbino2014(n-191)Emergencymedrotationstudentsusingcomputerbasedcases.Aim:reducediagnosticerrors.
Educationalinterventions (cognitiveforcingstrategies) toreduceerrorsfailed.
Stiegler2014Reviewofdecisionmakingmodelsandnonrational(notlogicalorpurelystatistically derived)factorsinanesthesiology.Strategiestorecognizeandrecoverfromerrors.
Cognitiveshortcuts,preferencesandemotionsinf luencerealworlddecisions.
Routinestrategiestomodifynonrationaldecisionfactorsdonothaveunequivocalsupport.
Normal2014(n=214)Tworesidentcohorts:onespeedyothercareful,reflectiveEachcomparedfordiagnosticaccuracy.
Noincreaseinaccuracy fortheref lectivecohort.
Blumenthal-Barby2015Revieworiginal,peerreviewedempiricalstudiesoncognitivebiasesandheuristicsinmedicaldecisionmaking(1980and2013,n-213)
Studiesonbiasandheuristicsof medicaldecisionmakingshouldfocusmoreonactualratherthanhypotheticalsituations. Patientsarestudiedmoreoftenthanmedicalpersonnel.Terminology usedincognitivebiasstudiesarenotstandardized.
Balogh2015.NAPBook.Reviewofevidenceaboutdiagnosticerrors,andrecommendationsforimprovement.
Mostpersonsexperience1diagnosticerror,andsomesufferseriousconsequences.Failedheuristicsandcognitivebiasesmayleadtoerrors.Effectsof debiasing,whiledebatable,maybehelpfulincertainsituationsasemergencyrooms.
Moreresearchinneededinthisarea.
Monteiro201547medicalresidents.Reflectandrevisediagnosesfor16cases.
Unstructuredref lectionofcaseshadasmallbenef it. Diagnosticperformanceismodulatedbyexperienceandknowledge
Smith,Black2015.Debiasingworkshopfor19familymedicineresidents.Objective:toincreaseresidentsawarenessoftheircognitivebiasleadingtomisdiagnosis.
Inspiteof positivetrends,statisticallysignif icantimprovementsdidnotoccur.
Educating traineephysiciansinrisksof biasandmisdiagnosismaynotbeeffective.
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DDeebbiiaassiinnggEEvviiddeenncceeRReevviieeww
WWhhaattddooeessiitttteelllluuss??
Therearemorestudies incognitivepsychology field, and farfewer inclinicalmedicine
Clinical &cognitive psychology fields need tocollaborate
Field needs tomature.Need real-life, not hypotheticalsituations
Some positive trends.Checklist inICUand surgeryCurriculum addition among trainees
Negativeresults also evident
Terminology notstandardized
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GGeenneerraallDDeebbiiaassiinngg aaddvviissee..
Typeofcognitiveerror
Debiasing,afterawarenessandacceptanceofneedforchange,
Confirmationbias Activelyseekdisconfirmingdata; isthereevidencecontradictingyourhypothesis?Considertheoppositeofyour diagnosis orsummation;disengage, when possible, from dual roleof treatingand being anexpertwitness
Hindsight/Retrospectivebias
Whilerenderinganopinion,considerwhatyourdecision(diagnosis)wouldhavebeenifyouwereblindtotheultimateoutcome
Baseratebias Beforeselectingcasespecificdiagnosisorconclusions,findouthowcommonthatdiagnosisis (baserates)amongthepossibilitiesinthatpopulation
Modified from Satya-Murti S, Lockhart J. Recognizing and reducing cognitive bias in clinical and forensic neurology. Neurol Clin Pract. 2015;5(5):389–396.
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De-biasingstrategiesOr,AnounceofBiaspreventionisworthapoundofDe-Biasing“Cure.”◦Biaspreventionshouldbeprimarygoal,withde-biasingtechniquesbeingsecondary.
◦Usede-biasingtechniques whenprevention isunavailable.
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Biaspreventionstrategy:“Linearsequentialunmasking”
LinearSequentialUnmasking(LSU)ApproachforMinimizingCognitiveBiasinForensicDecisionMaking(Dror etal.,2015)
Level1:TraceEvidence
Level2:Referencematerials
Level3:Caseinformation
Level4:"Baserate"expectations
Level5:Organizationalandculturalfactors
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BiasPreventionstrategiesControlpotentiallybiasinginformationfromthebeginningReviewmostvaliddatafirst,beforepotentiallybiased(prematureclosure,dxmomentum)•Avoid“diagnosticmomentum”byformingatentativeopinionBEFOREreadingotherexperts’conclusions• Thatway,youcanpinpointtheevidencethatchangedyouropinion
Sensitizeyourselftopotentialbiases(e.g.,Jenkins&Youngstrom,2016)
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GeneralDebiasing advise.Typeofcognitiveerror
Debiasing,afterawarenessandacceptanceofneedforchange,
Confirmationbias Activelyseekdisconfirmingdata;isthereevidencecontradictingyourhypothesis?Considertheoppositeofyourdiagnosisorsummation;disengage,whenpossible,fromdualroleoftreatingandbeinganexpertwitness
Baseratebias Beforeselectingcasespecificdiagnosisorconclusions,findouthowcommonthatdiagnosisis(baserates)amongthepossibilitiesinthatpopulation
Hindsight/Retrospectivebias
Whilerenderinganopinion,considerwhatyourdecisions(diagnosis)wouldhavebeenifyouwereblindtotheultimateoutcome
Modified from Satya-Murti S, Lockhart J. Recognizing and reducing cognitive bias in clinical and forensic neurology. Neurol Clin Pract. 2015;5(5):389–396.
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De-BiasingTechniques•Requireseffortfulprocessing(notmerely“reflection”).E.g.,activelyseekingoutevidencethatisinconsistentwithyourconclusion
•Usechecklists/objectivemeasureswhereavailable(e.g.,MacCAT-CA,ECSTinCSTevals).Witt(2010),MACSTChecklist,Skeem (1989)paperallincludedinmaterials
•Consultwithacolleaguewhohasminimal info,andwhoisnot afraidtodisagreewithyou.
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RReeccooggnniittiioonnooffBBiiaassmmaakkeessyyoouuaabbeetttteerreexxppeerrttWWiittnneessss::JJooeellDDvvoosskkiinnvIfyouonlyconsideronesideofthequestion,youarelesslikelytobeseenasacrediblewitness.
v“Thereisnosuchthingas‘THETRUTH.’“(onlyobjectivefactsandyouropinionabout them
vYouareevidence(likeamaggot,butnicer)
v“Showyourwork” letthereaderseetheevidencefor(andagainst)yourconclusion
vContinuallyaskyourself,“HowdoIknowthat?”
vRemember,“IT’sNOTABOUTYOU!”
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Thankyouforlistening toour
SatySatya-Murti&JosephLockhart
unbiasedpresentation
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LINKS TO ADDITIONAL RESOURCES
These are links to Dropbox files of articles for checklists to use in forensic report-writing:
1. Checklist for CST reports from MAhttps://www.dropbox.com/s/rz1jhc6trqd1mns/DubeCRreportwritingguidelinesrevised2002.pdf?dl=02. Skeem - Logic and relaibility of CST Evaluations (valuable tool for examining your reasoning)https://www.dropbox.com/s/cvovm4ihndudlbo/Skeem%20et%20al.%20-%201998%20-%20Logic%20and%20reliability%20of%20evaluations%20of%20competence%20copy.pdf?dl=03. Witt - General checklist for Forensic evaluationshttps://www.dropbox.com/s/rgfdaeqcj2vlyav/Witt%2C%20Phil%20-%20Forensic%20Psychology%20Report%20Checklist.pdf%20copy.pdf?dl=04. Grisso-Typical errors in forensic evaluationshttps://www.dropbox.com/s/jmcikysz4kb23vf/Grisso%25202010-2%5B1%5D.pdf?dl=0
Contact: Jerry Lockhart ([email protected])