Donald A. Redelmeier, MD
Acknowledgments: The author thanks Tracy Willson for administration support, and Chris Denny, MD, MSc; Edward Etchells, MD, MSc; Damon Scales, MD; Steven Shumak, MD; and Matthew Stanbrook, MD, PhD, for commenting on drafts of this manuscript.
Grant Support: By the Canada Research Chair in Medical Decision Sciences, Error Management Unit of Sunnybrook and Women's College Health Sciences Centre, and Canadian Institute for Health Research. These funding sources had no role in the design, conduct, or reporting of this project. Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Donald A. Redelmeier, MD, Sunnybrook and Women's College Health Sciences Centre, Room G-151, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5 Canada; e-mail, firstname.lastname@example.org.
Cognitive psychology is the science that examines how people reason, formulate judgments, and make decisions. This case involves a patient given a diagnosis of pharyngitis, whose ultimate diagnosis of osteomyelitis was missed through a series of cognitive shortcuts. These errors include the availability heuristic (in which people judge likelihood by how easily examples spring to mind), the anchoring heuristic (in which people stick with initial impressions), framing effects (in which people make different decisions depending on how information is presented), blind obedience (in which people stop thinking when confronted with authority), and premature closure (in which several alternatives are not pursued). Rather than trying to completely eliminate cognitive shortcuts (which often serve clinicians well), becoming aware of common errors might lead to sustained improvement in patient care.
Table. Selected Pitfalls Leading to Missed Diagnoses and Corrective Strategies
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David D Derauf
Kokua Kalihi Valley Health Center
January 19, 2005
Cogitating on Cognitive Errors
Dr. Redelmeier is to be thanked for his recent article "The Cognitive Psychology of Missed Diagnoses". I hope it will prove useful in my own clinical practice as well as in the teaching of clinical skills to medical students and residents.Regarding the framing pitfall, perhaps another clinical maxim to consider would be: "Never choose a frame too small for the picture". For it seems in my own experience that framing is often the act of narrowing a diagnosis through choice of words, the utility of which needs to be weighed against the danger of prematurely eliminating alternative explanations. In this sense, framing appears to be closely linked to premature closure. Regarding the underlying rationales for each type of cognitive error, the article mentioned "the ability to "produce the desired results with a minimum of delay, cost and anxiety". In addition, one would think that our perceived need as physicians to appear omniscient, or at least highly self -confident, may often underly common cognitive errors in arriving at a diagnosis. Expressing confidence in our diagnosis to the patient may be thought to be helpful in healing the patient or at least in increasing patient satisfaction with the visit, though evidence seems to be scanty for both of these.(1) To what extent might that underly some of the common cognitive errors in diagnosis seems to await further research.
1: Physician-patient communication in the primary care office: a systematic review.Beck RS, Daughtridge R, Sloane PD.J Am Board Fam Pract. 2002 Jan-Feb;15(1):25-38.
Ronald M Epstein
University of Rochester, Departments of Family Medicine and Psychiatry
February 18, 2005
Non-cognitive factors in diagnostic errors
The recent article by Redelmeier (The Cognitive Psychology of Missed Diagnoses. Ann Int Med 2005;142:115-120) provides a useful guide to mental processes that accompany cognitive errors in diagnostic reasoning. However, pragmatically, there are two pieces missing that might translate those insights into practical strategies for error reduction.
First, there should be some consideration of the involvement of emotions in rational decision making(1) Lack of sufficient emotional involvement can lead to carelessness and uncritical reliance on heuristics, whereas overactive emotions can generate paralyzing anxiety with similar lack of ability to achieve perspective (2). Thus, some capacity for recognition of one's own emotions -- both quantitatively and qualitatively -- can influence one's ability to recognize and accommodate to the heuristics being unconsciously employed.
Second is the embedded assumption that knowledge of the kinds of tricks one's mind can play is sufficient to prevent them. The level of self-awareness that the authors suggest is usually achieved with some effort, and should not be assumed to occur spontaneously. Some methods of achieving self awareness, familiar to performing artists, psychotherapists and athletes, have been adapted to medical training in a variety of forms: group formats that allow for reflection on the emotional content of clinical encounters (3), honing one's observational skills by viewing art or reading poetry (4), and writing narratives (5). Weick describes organizational features that promote mindfulness by rewarding transparency and disclosure, encouraging vigilance and fostering resilience that could be adapted to medical settings (6). Although the effort to reduce errors has increasingly focused on institutional factors, the creation of institutional cultures to foster individual self-awareness may also be an important ingredient in promoting recognition of and appropriate responses to faulty diagnostic reasoning.
Ronald Epstein, MD
(1) Damasio AR. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt Brace; 1999.
(2) Borrell-Carrio F, Epstein RM. Preventing Errors in Clinical Practice: A Call for Self-Awareness. Ann Fam Med 2004 July 1;2(4):310-6.
(3) Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: Personal awareness and effective patient care. Jama 1997;278(6):502-9.
(4) Connelly J. Being in the present moment: developing the capacity for mindfulness in medicine. Acad Med 1999 April;74(4):420-4.
(5) DasGupta S, Charon R. Personal illness narratives: using reflective writing to teach empathy. Academic Medicine 2004 April;79(4):351-6.
(6) Weick KM, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass; 2001.
Donald A Redelmeier
University of Toronto
April 27, 2005
Response from Original Article Author
To the Editor, Derauf provides some insightful feedback in a kindly manner. His introduction of another maxim is particularly welcome, as are his remarks about the role of confidence in medicine. In moderation, confidence is necessary because facing trouble requires courage, the stakes in medical care are high, and clinicians do not want to act capriciously. Taken to extreme, however, any self-deception is a source of fallibility. A valid rationale is what distinguishes confidence from self-deception.
Psychology research also shows that people sometimes are overly dependent on the rationale. In one study , students were offered an attractive vacation following a tough examination. By random assignment, a third were told they had passed; in this case, most accepted the offer (presumably as a reward). A third were told they had failed; in this case, most still accepted the offer (presumably as a consolation). The final third were told the examination results were delayed; in this case, most declined the offer. Apparently, the lack of a rationale dissuaded some students from accepting a vacation that was otherwise attractive regardless of circumstance. The general pattern is that even minor decisions require the presence of a rationale.
Biology is complex and patient presentations are uncertain; hence, a clinician may seek or construct all sorts of rationales. Once a rationale is obtained, such clinicians tend to lack the circumspection of dispassionate reviewers. As Derauf mentions, the self-deception underpins a basic vulnerability to framing effects and a failure to intercept errors. As Derauf also emphasizes, self-deception is sometimes reinforced by the patient. Alas, self-deception is a resource many of us have in abundance.
References  Tversky A, Shafir E. The disjunction effect in choice under uncertainty. Psychological Science 1992;3:305-9.
Redelmeier DA. The Cognitive Psychology of Missed Diagnoses. Ann Intern Med. 2005;142:115-120. doi: 10.7326/0003-4819-142-2-200501180-00010
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Published: Ann Intern Med. 2005;142(2):115-120.
Cardiac Diagnosis and Imaging, Cardiology, Education and Training, Emergency Medicine, Endocarditis.
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