Both systemic and individual factors contribute to missed or delayed diagnoses. Among the multiple factors that impact clinical performance of the individual, the caliber of cognition is perhaps the ...most relevant and deserves our attention and understanding. In the last few decades, cognitive psychologists have gained substantial insights into the processes that underlie cognition, and a new, universal model of reasoning and decision making has emerged, Dual Process Theory. The theory has immediate application to medical decision making and provides an overall schema for understanding the variety of theoretical approaches that have been taken in the past. The model has important practical applications for decision making across the multiple domains of healthcare, and may be used as a template for teaching decision theory, as well as a platform for future research. Importantly, specific operating characteristics of the model explain how diagnostic failure occurs.
In the area of patient safety, recent attention has focused on diagnostic error. The reduction of diagnostic error is an important goal because of its associated morbidity and potential ...preventability. A critical subset of diagnostic errors arises through cognitive errors, especially those associated with failures in perception, failed heuristics, and biases; collectively, these have been referred to as cognitive dispositions to respond (CDRs). Historically, models of decision-making have given insufficient attention to the contribution of such biases, and there has been a prevailing pessimism against improving cognitive performance through debiasing techniques. Recent work has catalogued the major cognitive biases in medicine; the author lists these and describes a number of strategies for reducing them ("cognitive debiasing"). Principle among them is metacognition, a reflective approach to problem solving that involves stepping back from the immediate problem to examine and reflect on the thinking process. Further research effort should be directed at a full and complete description and analysis of CDRs in the context of medicine and the development of techniques for avoiding their associated adverse outcomes. Considerable potential exists for reducing cognitive diagnostic errors with this approach. The author provides an extensive list of CDRs and a list of strategies to reduce diagnostic errors.
Clinical decision making is a cornerstone of high‐quality care in emergency medicine. The density of decision making is unusually high in this unique milieu, and a combination of strategies has ...necessarily evolved to manage the load. In addition to the traditional hypothetico‐deductive method, emergency physicians use several other approaches, principal among which are heuristics. These cognitive short‐cutting strategies are especially adaptive under the time and resource limitations that prevail in many emergency departments (EDs), but occasionally they fail. When they do, we refer to them as cognitive errors. They are costly but highly preventable. It is important that emergency physicians be aware of the nature and extent of these heuristics and biases, or cognitive dispositions to respond (CDRs). Thirty are catalogued in this article, together with descriptions of their properties as well as the impact they have on clinical decision making in the ED. Strategies are delineated in each case, to minimize their occurrence. Detection and recognition of these cognitive phenomena are a first step in achieving cognitive de‐biasing to improve clinical decision making in the ED.
Clinical judgment is a critical aspect of physician performance in medicine. It is essential in the formulation of a diagnosis and key to the effective and safe management of patients. Yet, the ...overall diagnostic error rate remains unacceptably high. In more than four decades of research, a variety of approaches have been taken, but a consensus approach toward diagnostic decision making has not emerged. In the last 20 years, important gains have been made in psychological research on human judgment. Dual-process theory has emerged as the predominant approach, positing two systems of decision making, System 1 (heuristic, intuitive) and System 2 (systematic, analytical). The author proposes a schematic model that uses the theory to develop a universal approach toward clinical decision making. Properties of the model explain many of the observed characteristics of physicians' performance. Yet the author cautions that not all medical reasoning and decision making falls neatly into one or the other of the model's systems, even though they provide a basic framework incorporating the recognized diverse approaches. He also emphasizes the complexity of decision making in actual clinical situations and the urgent need for more research to help clinicians gain additional insight and understanding regarding their decision making.
Overconfidence in Clinical Decision Making Croskerry, Pat, MD, PhD; Norman, Geoff, PhD
The American journal of medicine,
05/2008, Letnik:
121, Številka:
5
Journal Article
Recenzirano
Croskerry and Norman comments on the article by Berner and Graber, which regards to modes of diagnostic decision making and their relationship to the phenomenon of overconfidence. Effective problem ...solving, sound judgment, and well-calibrated clinical decision making are considered to be among the highest attributes of physicians. Surprisingly, however. this important area has been actively researched for only about 35 years. Thus, the effortless pattern recognition that characterizes the clinical acumen of the expert physician is made possible by accretion of a vast experience that eventually allows the process to devolve to an automatic level.
Aim: Recently, a growing awareness has developed of the extraordinary complexity of factors that influence the clinical reasoning underpinning the diagnostic process. The aim of the present report is ...to delineate these factors and suggest strategies for dealing more effectively with this complexity.
Method: Six major clusters of factors are described here: (A) individual characteristics of the decision maker, (B) individual intellectual and cognitive styles, (C) ambient and homeostatic factors, (D) factors in the work environment including team factors, (E) characteristics of the medical condition, and (F) factors associated with the patient. Additional factors, such as health care systems, culture, politics, and others are also important.
Results: A review of the literature suggests that most clinicians trained under existing methods achieve a level of expertise presently referred to as "routine" or "classic." The results of studies of diagnostic failure, however, suggest that this level of expertise has proved insufficient. A growing literature suggests that more effective clinical decision might be achieved through adaptive reasoning, leading to enhanced levels of expertise and mastery.
Conclusions: It is proposed here that adaptive expertise may be achieved through emphasizing additional features of the reasoning process: being aware of the inhibitors and facilitators of rationality; pursuing the standards of critical thinking; developing a comprehensive awareness of cognitive and affective biases and how to mitigate them; developing a similar depth and understanding of logic and its fallacies; engaging metacognitive processes such as reflection and mindfulness; and through approaches embracing creativity, lateral thinking, and innovation.
PDF
