Recognizing Clinical Reasoning Errors

Heidi Chumley, MD

Associate Professor, Family Medicine

Session Objectives

• At the end of this session, participants should be able to: – Outline the steps of the clinical reasoning

process.– Define cognitive dispositions to respond

(CDRs) and describe several CDRs seen with diagnostic reasoning errors.

– Recognize clinical reasoning errors in common educational settings.

Clinical Reasoning

• “the cognitive process necessary to evaluate and manage a medical problem”

Reasoning

KnowledgeSkill

Medical Errors

• 44,000 to 98,000 deaths per year due to medical errors

• Many systematic and individual factors contribute to medical errors

• Recent attention on cognitive errors (clinical reasoning, diagnostic reasoning, decision-making)

Cognitive Errors

Zhang, JAMIA, 2002

Cognitive Errors

• Of 301 Malpractice claims, 59% involved diagnostic errors that led to poor outcomes – Gandhi, 2006

• Of patients admitted with 10 days of outpatient visit, 10% due to diagnostic error – Singh, 2007

• Autopsy series showed 24% missed diagnosis – Shojania, 2003

Diagnostic process

Diagnosis Verification

Diagnosis Refinement

Differential Diagnosis Generation

Information gathering

Why are errors made?

• Failure/delay of eliciting information – Singh, 2007

• Suboptimal weighing of critical pieces of information from H&P – Singh, 2007

• Overreliance on diagnostic testing – Bordage, 1999

Cognitive Dispositions to Respond

• Biases that can lead to diagnostic errors

• Mental shortcuts running amuck

• Croskerry defines 32, Acad Med, 2003: 78(8)

Cognitive Dispositions to Respond

• Information-gathering– Unpacking– Availability– Anchoring– Premature closure

• System– Diagnosis momentum– Feedback sanction– Triage cueing

• Probability– Aggregate bias– Base-rate neglect– Gender bias– Gambler’s fallacy– Posterior probability

error

Croskerry, 2003

Information-gathering problems

• Unpacking – failure to elicit all relevant information

• Availability – recent exposure influences diagnosis

• Anchoring – holding onto a diagnosis after receiving contradictory information

• Premature closure – accepting a diagnosis before it is fully verified

Present at all levels, start watching for these in students

Clues to Information-Gathering Problems

• Limited differential diagnosis (unpacking, availability)

• Lack of attention to contradictory information (anchoring)

• Lack of pertinent negatives (premature closure)

Diagnostic Errors

Diagnosis Verification

Diagnosis Refinement

Differential Diagnosis Generation

Information gathering

Unpacking Availability

Anchoring

Premature closure

Systems contributions

• Diagnosis momentum – early diagnosis by another provider is accepted as definite

• Feedback sanction – final diagnosis does not return to initial decision-maker

• Triage cueing – location cues management (seen through the lens of the first provider)

Present at all levels, more likely to see in residents

Clues to System Contributors

• Lack of primary symptom data (diagnostic momentum)

• Inattention to closing the loop (feedback sanction)

• Non diagnoses: non-cardiac chest pain; no gynecologic cause for lower abdominal pain (triage cueing)

Probability Pitfalls

• Aggregate bias – aggregate data do not apply to my patients

• Base-rate neglect – ignoring the true prevalence

• Gender bias – gender inappropriately colors probability

• Gambler’s fallacy – sequence of same diagnoses will not continue

• Posterior probability – sequence of same diagnoses will continue

Best seen during continuity experiences, residency

Clues to Probability Pitfalls

• Didn’t meet criteria, but I…(aggregate)

• Rare diagnoses high on list, increased testing (base-rate neglect)

• Comments about probability (Gambler’s fallacy, posterior probability)

Two Others

• Representative restraint – ruled out because the presentation is not typical

• Search satisfying – search is called off when something is found

Summing Up

• Reasoning errors are common

• Identifying/naming the CDRs is an important part of reflection

• No gold standard for assessing reasoning in our learners – nothing to replace our conversations and helping them think about how they are thinking

• Are cognitive errors treatable? Yes

Questions?