COGNITIVE errors make a significant contribution to misdiagnoses particularly in highly complex and dynamic situations such as emergency medicine or where pressures if time preclude adequate time for reflection. Cognitive dispositions to Respond (CDRs) are a subset of cognitive errors that relate to:
- failures of perception;
- failed heuristics;
- biases.
Making good medical decisions is extremely difficult if you are already “hard-wired” not to collect good data (failures of perception), process it inexpertly (failed heuristics) or disregard it
anyway (biases). The tendency in the past has been for us to assume that we are all unbiased scientists dealing accurately with
the information in front of us and never deviating from best practice or making an error. To challenge this somewhat utopian view was to potentially open ourselves to a world of angst about subjects that it was thought we could not change. However, developments in the last 15 to 20 years now provide us with a ore optimistic view of what is possible and how we might achieve it.
Improving understanding
Cognitive psychology has generated an ever improving understanding of how the clinician’s mind works and from that comes the opportunity to consciously train and develop our cognitive skills. Neuroscience has demonstrated that many of the taken-for-granted “habits of thinking” are not fixed but are available to be trained and retrained by those prepared to do so. In her 2003 article, Crosskerry brought together more than 30 CDRs associated with the diagnostic process; an abridged list is given
in Table 1. Development as a self-responsible professional involves a number of steps (Figure. 1); this article aims to raise awareness of CDRs and to provide those prepared to take it, the opportunity to take the first steps forward. The first step is to raise awareness of CDRs in general and specifically to those which are most common within oneself. This can be done in a variety of ways.
Raise your awareness and knowledge
Just reading about the CDRs in Table 1 will raise your awareness and knowledge; you may well recognise some as more obvious in yourself than others. Alternatively, there is a range of reflective activities such as keeping a “learning log” or completing “critical
incident” summaries, particularly for events that do not go as expected, which can encourage a more analytical approach to your work. The second step is to take responsibility for the CDRs you identify. This is simple but not all that easy in that you will be seeking to change what are probably deeply ingrained habits of which you are probably only partially aware. You might best work with your peers or perhaps a clinical coach or mentor here. Once you have developed an awareness and taken responsibility, it is possible to further develop metacognitive (thinking about thinking) skills, to come to recognise incongruity, ambiguity, atypical presentations, and instances when data are not fitting together and then apply cognitive forcing strategies. These introduce a specific, conscious “debiasing” step that monitors your own decision-making process.
We can now dissect and analyse…
Of course, expert clinicians have been behaving in this way for decades before “metacognition” was first described in the 1970s but usually via a tacit path. The advantage now is that we can, in an explicit way, dissect, analyse, and gain an understanding of that goes into expertise in clinical decision making. By knowing more about this, it also allows us to train students and inexperienced clinicians in metacognitive skills, shortening and easing their path to expertise. If you would like to know more on the subject or would like to join a free webinar on the subject, please e-mail
christopherwhipp@aol.com.
References
Crosskerry, P. (2003) The importance of cognitive errors in diagnosis and strategies to minimise them. Acad Med 78 (8): 775-780.
Crosskerry P. (2003) Cognitive forcing strategies in clinical decision making. Ann Emerg Med 41: 110-120.
