An elderly woman with ‘heart failure’: Cognitive biases and diagnostic error

CASE CONTINUED: MORBIDITY AND MORTALITY CONFERENCE

The patient’s case is brought to a morbidity and mortality conference for discussion. The systems issues in the case—including medication reconciliation, availability of interpreters, and timing and process of echocardiogram readings—are all discussed, but clinical reasoning and cognitive errors made in the case are avoided.

Why are cognitive errors often neglected in discussions of medical error?

Historically, openly discussing error in medicine has been difficult. Over the past decade, however, and fueled by the landmark Institute of Medicine report To Err is Human,³⁴ the healthcare community has made substantial strides in identifying and talking about systems factors as a cause of preventable medical error.^34,35

While systems contributions to medical error are inherently “external” to physicians and other healthcare providers, the cognitive contributions to error are inherently “internal” and are often considered personal. This has led to diagnostic error being kept out of many patient safety conversations. Further, while the solutions to systems errors are often tangible, such as implementing a fall prevention program or changing the physical packaging of a medication to reduce a medication dispensing or administration error, solutions to cognitive errors are generally considered more challenging to address by organizations trying to improve patient safety.

How can hospitals and department leaders do better?

Healthcare organizations and leaders of clinical teams or departments can implement several strategies.³⁶

First, they can seek out and analyze the causes of diagnostic errors that are occurring locally in their institution and learn from their diagnostic errors, such as the one in our clinical scenario.

Trainees, physicians, and nurses should be comfortable questioning each other

Second, they can promote a culture of open communication and questioning around diagnosis. Trainees, physicians, and nurses should be comfortable questioning each other, including those higher up in the hierarchy, by saying, “I’m not sure” or “What else could this be?” to help reduce cognitive bias and expand the diagnostic possibilities.

Similarly, developing strategies to promote feedback on diagnosis among physicians will allow us all to learn from our diagnostic mistakes.

Use of the electronic medical record to assist in follow-up of pending diagnostic studies and patient return visits is yet another strategy.

Finally, healthcare organizations can adopt strategies to promote patient involvement in diagnosis, such as providing patients with copies of their test results and discharge summaries, encouraging the use of electronic patient communication portals, and empowering patients to ask questions related to their diagnosis. Prioritizing potential solutions to reduce diagnostic errors may be helpful in situations, depending on the context and environment, in which all proposed interventions may not be possible.

CASE CONTINUED: LEARNING FROM MISTAKES

The attending physician and resident in the case meet after the conference to review their clinical decision-making. Both are interested in learning from this case and improving their diagnostic skills in the future.

What specific steps can clinicians take to mitigate cognitive bias in daily practice?

In addition to continuing to expand one’s medical knowledge and gain more clinical experience, we can suggest several small steps to busy clinicians, taken individually or in combination with others that may improve diagnostic skills by reducing the potential for biased thinking in clinical practice.

From Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ 2009; 14:27–35. With kind permission from Springer Science and Business Media.

Think about your thinking. Our first recommendation would be to become more familiar with the dual process theory of clinical cognition (Figure 1).^37,38 This theoretical framework may be very helpful as a foundation from which to build better thinking skills. Physicians, especially residents, and students can be taught these concepts and their potential to contribute to diagnostic errors, and can use these skills to recognize those contributions in others’ diagnostic practices and even in their own.³⁹

Facilitating metacognition, or “thinking about one’s thinking,” may help clinicians catch themselves in thinking traps and provide the opportunity to reflect on biases retrospectively, as a double check or an opportunity to learn from a mistake.

Recognize your emotions. Gaining an understanding of the effect of one’s emotions on decision-making also can help clinicians free themselves of bias. As human beings, healthcare professionals are  susceptible to emotion, and the best approach to mitigate the emotional influences may be to consciously name them and adjust for them.⁴⁰

Because it is impractical to apply slow, analytical system 2 approaches to every case, skills that hone and develop more accurate, reliable system 1 thinking are crucial. Gaining broad exposure to increased numbers of cases may be the most reliable way to build an experiential repertoire of “illness scripts,” but there are ways to increase the experiential value of any case with a few techniques that have potential to promote better intuition.⁴¹

Embracing uncertainty in the early diagnostic process and envisioning the worst-case scenario in a case allows the consideration of additional diagnostic paths outside of the current working diagnosis, potentially priming the clinician to look for and recognize early warning signs that could argue against the initial diagnosis at a time when an adjustment could be made to prevent a bad outcome.

Practice progressive problem-solving,⁴² a technique in which the physician creates additional challenges to increase the cognitive burden of a “routine” case in an effort to train his or her mind and sharpen intuition. An example of this practice is contemplating a backup treatment plan in advance in the event of a poor response to or an adverse effect of treatment. Highly rated physicians and teachers perform this regularly.^43,44 Other ways to maximize the learning value of an individual case include seeking feedback on patient outcomes, especially when a patient has been discharged or transferred to another provider’s care, or when the physician goes off service.

Simulation, traditionally used for procedural training, has potential as well. Cognitive simulation, such as case reports or virtual patient modules, have potential to enhance clinical reasoning skills as well, though possibly at greater cost of time and expense.

Decreased reliance on memory is likely to improve diagnostic reasoning. Systems tools such as checklists⁴⁵ and health information technology⁴⁶ have potential to reduce diagnostic errors, not by taking thinking away from the clinician but by relieving the cognitive load enough to facilitate greater effort toward reasoning.

Slow down. Finally, and perhaps most important, recent models of clinical expertise have suggested that mastery comes from having a robust intuitive method, with a sense of the limitations of the intuitive approach, an ability to recognize the need to perform more analytical reasoning in select cases, and the willingness to do so. In short, it may well be that the hallmark of a master clinician is the propensity to slow down when necessary.⁴⁷

A ‘diagnostic time-out’ for safety might catch opportunities to recognize and mitigate biases and errors

If one considers diagnosis a cognitive procedure, perhaps a brief “diagnostic time-out” for safety might afford an opportunity to recognize and mitigate biases and errors. There are likely many potential scripts for a good diagnostic time-out, but to be functional it should be brief and simple to facilitate consistent use. We have recommended the following four questions to our residents as a starting point, any of which could signal the need to switch to a slower, analytic approach.

Four-step diagnostic time-out

• What else can it be?
• Is there anything about the case that does not fit?
• Is it possible that multiple processes are going on?
• Do I need to slow down?

These questions can serve as a double check for an intuitively formed initial working diagnosis, incorporating many of the principles discussed above, in a way that would hopefully avoid undue burden on a busy clinician. These techniques, it must be acknowledged, have not yet been directly tied to reductions in diagnostic errors. However, diagnostic errors, as discussed, are very difficult to identify and study, and these techniques will serve mainly to improve habits that are likely to show benefits over much longer time periods than most studies can measure.