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The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them

Croskerry, Pat MD, PhD

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Author Information

Dr. Croskerry is associate professor, Departments of Emergency Medicine and Medical Education, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada. He is also a member of the Center for Safety in Emergency Care, a research consortium of the University of Florida College of Medicine, Dalhousie University Faculty of Medicine, Northwestern University The Feinberg School of Medicine, and Brown Medical School.

Correspondence and requests for reprints should be sent to Dr. Croskerry, Emergency Department, Dartmouth General Hospital Site, Capital District, 325 Pleasant Street, Dartmouth, Nova Scotia, Canada B2Y 4G8; telephone: (902) 465-8491; fax: (902) 460-4148; e-mail: 〈〉.

The author gratefully acknowledges support through a Senior Clinical Research Fellowship from the Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, and a grant (#P20HS11592-02) awarded by the Agency for Healthcare Research and Quality.

Two responses to this article are printed after it.

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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.

The recent article by Graber et al.1 provides a comprehensive overview of diagnostic errors in medicine. There is, indeed, a long overdue and pressing need to focus on this area. They raise many important points, several of which deserve extra emphasis in the light of recent developments. They also provide an important conceptual framework within which strategies may be developed to minimize errors in this critical aspect of patient safety. Diagnostic errors are associated with a proportionately higher morbidity than is the case with other types of medical errors.2–4

The no-fault and system-related categories of diagnostic errors described1 certainly have the potential for reduction. In fact, very simple changes to the system could result in a significant reduction in these errors. However, the greatest challenge, as they note, is the minimization of cognitive errors, and specifically the biases and failed heuristics that underlie them. Historically, there has prevailed an unduly negative mood toward tackling cognitive bias and finding ways to minimize or eliminate it.

The cognitive revolution in psychology that took place over the last 30 years gave rise to an extensive, empirical literature on cognitive bias in decision-making, but this advance has been ponderously slow to enter medicine. Decision-making theorists in medicine have clung to normative, often robotic, models of clinical decision making that have little practical application in the real world of decision making. What is needed, instead, is a systematic analysis of what Reason5 has called “flesh and blood” decision-making. This is the real decision making that occurs at the front line, when resources are in short supply, when time constraints apply, and when shortcuts are being sought. When we look more closely at exactly what cognitive activity is occurring when these clinical decisions are being made, we may be struck by how far it is removed from what normative theory describes. Although it seems certain we would be less likely to fail patients diagnostically when we follow rational, normative models of decision making, and although such models are deserving of “a prominent place in Plato's heaven of ideas,”6 they are impractical at the sharp end of patient care. Cognitive diagnostic failure is inevitable when exigencies of the clinical workplace do not allow such Olympian cerebral approaches.

Medical decision makers and educators have to do three things: (1) appreciate the full impact of diagnostic errors in medicine and the contribution of cognitive errors in particular; (2) refute the inevitability of cognitive diagnostic errors; and (3) dismiss the pessimism that surrounds approaches for lessening cognitive bias.

For the first, the specialties in which diagnostic uncertainty is most evident and in which delayed or missed diagnoses are most likely are internal, family, and emergency medicine; this is borne out in findings from the benchmark studies of medical error.2–4 However, all specialties are vulnerable to this particular adverse event. The often impalpable nature of diagnostic error perhaps reflects why it does not appear in lists of serious reportable events.7 For the second, there needs to be greater understanding of the origins of the widespread inertia that prevails against reducing or eliminating cognitive errors. This inertia may exist because such errors appear to be so predictable, so widespread among all walks of life, so firmly entrenched, and, therefore, probably hardwired. Although the evolutionary imperatives that spawned them may have served us well in earlier times, it now seems we are left with cognitively vestigial approaches to the complex decision making required of us in the modern world. Although “cognitive firewalls” may have evolved to quarantine or avoid cognitive errors, they are clearly imperfect8 and will require ontogenetic assistance (i.e., cognitive debiasing) to avoid their consequences. Accepting this, we should say less about biases and failed heuristics and more about cognitive dispositions to respond (CDRs) to particular situations in various predictable ways. Removing the stigma of bias clears the way toward accepting the capricious nature of decision-making, and perhaps goes some way toward exculpating clinicians when their diagnoses fail.

An understanding of why clinicians have particular CDRs in particular clinical situations will throw considerable light on cognitive diagnostic errors. The unmasking of cognitive errors in the diagnostic process then allows for the development of debiasing techniques. This should be the ultimate goal, and it is not unrealistic.

Certainly, a number of clear strategies exist for reducing the memory limitations and excessive cognitive loading1 that can lead to diagnostic errors, but the most important strategy may well lie in familiarizing clinicians with the various types of CDRs that are out there, and how they might be avoided. I made a recent extensive trawl of medical and psychological literature, which revealed at least 30 CDRs,9 and there are probably more (List 1). This catalogue provides some idea of the extent of cognitive bias on decision-making and gives us a working language to describe it. The failures to show improvement in decision support for clinical diagnosis that are noted by Graber et al.1 should come as no surprise. They are likely due to insufficient awareness of the influence of these CDRs, which is often subtle and covert.10 There appears to have been an historic failure to fully appreciate, and therefore capture, where the most significant diagnostic failures are coming from.

List 1
List 1
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List 1
List 1
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Not surprisingly, all CDRs are evident in emergency medicine, a discipline that has been described as a “natural laboratory of error.”11 In this milieu, decision-making is often naked and raw, with its flaws highly visible. Nowhere in medicine is rationality more bounded by relatively poor access to information and with limited time to process it, all within a milieu renowned for its error-producing conditions.12 It is where heuristics dominate, and without them emergency departments would inexorably grind to a halt.13 Best of all, for those who would like to study real decision making, it is where heuristics can be seen to catastrophically fail. Approximately half of all litigation brought against emergency physicians arises from delayed or missed diagnoses.14

If we accept the pervasiveness and predictability of the CDRs that underlie diagnostic cognitive error, then we are obliged to search for effective debiasing techniques. Despite the prevailing pessimism, it has been demonstrated that, using a variety of strategies15,16 (Table 1), CDRs can be overcome for a number of specific biases.16–23 It appears that there are, indeed, cognitive pills for cognitive ills,22 which makes intuitive sense. This is fortunate, for otherwise, how would we learn to avoid pitfalls, develop expertise, and acquire clinical acumen, particularly if the predisposition for certain cognitive errors is hardwired? However, medical educators should be aware that if the pills are not sufficiently sugared, they may not be swallowed.

Table 1
Table 1
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Yates et al.24 have summarized some of the major impediments that have stood in the way of developing effective cognitive debiasing strategies, and they are not insurmountable. The first step is to overcome the bias against overcoming bias. Metacognition will likely be the mainstay of this approach. A recent cognitive debiasing technique using cognitive forcing strategies is based on metacognitive principles10 and seems to be teachable to medical undergraduates and postgraduates.25 Essentially, the strategy requires first that the learner be aware of the various cognitive pitfalls, and second that specific forcing strategies be developed to counter them.

Much of clinical decision making, as Reason5 notes, is where “the cognitive reality departs from the formalized ideal.” This cognitive reality is extremely vulnerable to error. The problem is that cognitive error is high-hanging fruit and difficult to get at, and there will be a tendency to pursue more readily attainable goals. There is a story about a jogger who came across a man on his knees under a streetlight one evening. He explained that he had dropped his wedding ring. The jogger offered to help him search, and he accepted. With no luck after a half hour, the jogger asked the man if he was sure he had dropped the ring at the place where they were searching. The man replied that he actually dropped it several yards away in the shadows. “Then why are we looking here?” asked the jogger. “Because the light is better,” came the reply.

Real solutions to cognitive diagnostic errors lie in the shadows, and they will be difficult to find. One very clear goal in reducing diagnostic errors in medicine is to first describe, analyze, and research CDRs in the context of medical decision making, and to then find effective ways of cognitively debiasing ourselves and those whom we teach. Not only should we be able to reduce many cognitive diagnostic errors, but we may also be pleasantly surprised to find how many can be eliminated.

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2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1. N Eng J Med. 1991;324:370–6.

3. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Australia 1995;163:458–71.

4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–2.

5. Reason, J. Human Error. New York: Cambridge University Press, 1990.

6. Simon HA. Alternate visions of rationality. In: Arkes HR, Hammond KR (eds.). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 97–113.

7. Serious reportable events in patient safety: A National Quality Forum consensus report. Washington, D.C.: National Quality Forum, 2002.

8. Cosmides L, Tooby J. Consider the source: the evolution of adaptations for decoupling and metarepresentation. In: Sperber D (ed.). Metarepresentation. Vancouver Studies in Cognitive Science. New York: Oxford University Press, 2001.

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10. Croskerry P. Cognitive forcing strategies in clinical decision making. Ann Emerg Med. 2003;41:110–20.

11. Bogner, MS. (ed.). Human Error in Medicine. New Jersey: Lawrence Erlbaum Associates, 1994.

12. Croskerry P, Wears RL. Safety errors in emergency medicine. In: Markovchick VJ and Pons PT (eds.). Emergency Medicine Secrets, 3rd ed. Philadelphia: Hanley and Belfus, 2002: 29–37.

13. Kovacs G, Croskerry P. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999;6:947–52.

14. Data from the U.S General Accounting Office, the Ohio Hospital Association and the St. Paul (MN) Insurance Company, 1998 〈〉. Accessed 4/24/03.

15. Fischhoff B. Debiasing. In: Kahneman D. Slovic P. and Tversky A (eds). Judgment under Uncertainty: Heuristics and Biases. New York: Cambridge University Press, 1982: 422–44.

16. Arkes HA. Impediments to accurate clinical judgment and possible ways to minimize their impact. In: Arkes HR, Hammond KR (eds). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 582–92.

17. Nathanson S, Brockner J, Brenner D, et al. Toward the reduction of entrapment. J Applied Soc Psychol. 1982;12:193–208.

18. Schwartz WB, Gorry GA, Kassirer JP, Essig A. Decision analysis and clinical judgment. Am J Med. 1973;55:459–72.

19. Slovic P, Fischhoff B. On the psychology of experimental surprises. J Exp Psychol Hum Percept Perform. 1977;3:544–51.

20. Edwards W, von Winterfeldt D. On cognitive illusions and their implications. In: Arkes HR, Hammond KR (eds). Judgment and Decision Making: An Interdisciplinary Reader. New York: Cambridge University Press, 1986: 642–79.

21. Wolf FM, Gruppen LD, Billi JE. Use of a competing-hypothesis heuristic to reduce pseudodiagnosticity. J Med Educ 1988;63:548–54.

22. Keren G. Cognitive aids and debiasing methods: can cognitive pills cure cognitive ills? In: Caverni JP, Fabre JM, Gonzales M (eds). Cognitive Biases. New York: Elsevier, 1990: 523–52.

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24. Yates JF, Veinott ES, Patalano AL. Hard decisions, bad decisions: on decision quality and decision aiding. In: Schneider S, Shanteau J. (eds.). Emerging Perspectives in Judgment and Decision Making. New York: Cambridge University Press, 2003.

25. Croskerry P. Cognitive forcing strategies in emergency medicine. Emerg Med J. 2002;19(suppl 1):A9.

26. Croskerry P. The feedback sanction. Acad Emerg Med. 2000;7:1232–38.

27. Hogarth RM. Judgment and Choice: The Psychology of Decision. Chichester, England: Wiley, 1980.

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Annals of Emergency Medicine
Randomized Trial of Computerized Quantitative Pretest Probability in Low-Risk Chest Pain Patients: Effect on Safety and Resource Use
Kline, JA; Zeitouni, RA; Hernandez-Nino, J; Jones, AE
Annals of Emergency Medicine, 53(6): 727-735.
Annals of Emergency Medicine
Do Emergency Physicians Attribute Drug-Related Emergency Department Visits to Medication-Related Problems?
Hohl, CM; Zed, PJ; Brubacher, JR; Abu-Laban, RB; Loewen, PS; Purssell, RA
Annals of Emergency Medicine, 55(6): 493-502.
Inflammation Research
On the origins and development of evidence-based medicine and medical decision making
Elstein, AS
Inflammation Research, 53(): S184-S189.
Academic Emergency Medicine
The use of simulation in emergency medicine: A research agenda
Bond, WF; Lammers, RL; Spillane, LL; Smith-Coggins, R; Fernandez, R; Reznek, MA; Vozenilek, JA; Gordon, JA
Academic Emergency Medicine, 14(4): 353-363.
Journal of Empirical Research on Human Research Ethics
Personality and ethical decision-making in research: The role of perceptions of self and others
Antes, AL; Brown, RP; Murphy, ST; Waples, EP; Mumford, MD; Connelly, S; Devenport, LD
Journal of Empirical Research on Human Research Ethics, 2(4): 15-34.
Nordic Journal of Psychiatry
Barriers in the help-seeking process: A multiple-case study of early-onset dysthymia in Sweden
Svanborg, C; Rosso, MS; Lutzen, K; Wistedt, AA; Baarnhielm, S
Nordic Journal of Psychiatry, 62(5): 346-353.
Advances in Health Sciences Education
Thinking about diagnostic thinking: a 30-year perspective
Elstein, AS
Advances in Health Sciences Education, 14(): 7-18.
Social Science & Medicine
What do physicians gain (and lose) with experience? Qualitative results from a cross-national study of diabetes
Elstad, EA; Lutfey, KE; Marceau, LD; Campbell, SM; von dem Knesebeck, O; McKinlay, JB
Social Science & Medicine, 70(): 1728-1736.
Journal of Evaluation in Clinical Practice
Diagnostic errors and reflective practice in medicine
Mamede, S; Schmidt, HG; Rikers, R
Journal of Evaluation in Clinical Practice, 13(1): 138-145.
Medical Teacher
Twelve tips for teaching avoidance of diagnostic errors
Trowbridge, RL
Medical Teacher, 30(5): 496-500.
Peer Review: The Success of Headache Depends On Us!
Taylor, FR
Headache, 49(): S66-S69.
Family Medicine
Probability Error in Diagnosis: The Conjunction Fallacy Among Beginning Medical Students
Rao, G
Family Medicine, 41(4): 262-265.

Annals of Emergency Medicine
Improving Handoffs in the Emergency Department
Cheung, DS; Kelly, JJ; Beach, C; Berkeley, RP; Bitterman, RA; Broida, RI; Dalsey, WC; Farley, HL; Fuller, DC; Garvey, DJ; Klauer, KM; McCullough, LB; Patterson, ES; Pham, JC; Phelan, MP; Pines, JM; Schenkel, SM; Tomolo, A; Turbiak, TW; Vozenilek, JA; Wears, RL; White, ML
Annals of Emergency Medicine, 55(2): 171-180.
Information Systems Research
DSS effectiveness in marketing resource allocation decisions: Reality vs. perception
Lilien, GL; Rangaswamy, A; Van Bruggen, GH; Starke, K
Information Systems Research, 15(3): 216-235.
Academic Emergency Medicine
Cognitive and social issues in emergency medicine knowledge translation: A research agenda
Brehaut, JC; Hamm, R; Majumdar, S; Papa, F; Lott, A; Lang, E
Academic Emergency Medicine, 14(): 984-990.
Medical Education
Breaking down automaticity: case ambiguity and the shift to reflective approaches in clinical reasoning
Mamede, S; Schmidt, HG; Rikers, RMJP; Penaforte, JC; Coelho-Filho, JM
Medical Education, 41(): 1185-1192.
Human Factors
Human Factors of the Confirmation Bias in Intelligence Analysis: Decision Support From Graphical Evidence Landscapes
Cook, MB; Smallman, HS
Human Factors, 50(5): 745-754.
Journal of the American Medical Informatics Association
Can Cognitive Biases during Consumer Health Information Searches Be Reduced to Improve Decision Making?
Lau, AYS; Coieera, EW
Journal of the American Medical Informatics Association, 16(1): 54-65.
Academic Emergency Medicine
Clinical information systems: Instant ubiquitous clinical data for error reduction and improved clinical outcomes
Feied, CF; Handler, JA; Smith, MS; Gillam, M; Kanhouwa, M; Rothenhaus, T; Conover, K; Shannon, T
Academic Emergency Medicine, 11(): 1162-1169.
Missed diagnosis of subarachnoid hemorrhage in the emergency department
Vermeulen, MJ; Schull, MJ
Stroke, 38(4): 1216-1221.
Annals of Emergency Medicine
Characteristics of patient care management problems identified in emergency department morbidity and mortality investigations during 15 years
Cosby, KS; Roberts, R; Palivos, L; Ross, C; Schaider, J; Sherman, S; Nasr, I; Couture, E; Lee, M; Schabowski, S; Ahmad, I; Scott, RD
Annals of Emergency Medicine, 51(3): 251-261.
Quality & Safety in Health Care
Understanding diagnostic errors in medicine: a lesson from aviation
Singh, H; Petersen, LA; Thomas, EJ
Quality & Safety in Health Care, 15(3): 159-164.
Journal of Clinical Ethics
Diagnosing PVS and minimally conscious state: The role of tacit knowledge and intuition
White, MT
Journal of Clinical Ethics, 17(1): 62-71.

Annals of Emergency Medicine
Emergency physicians and disclosure of medical errors
Moskop, JC; Geiderman, JM; Hobgood, CD; Larkin, GL
Annals of Emergency Medicine, 48(5): 523-531.
Surgical Clinics of North America
Patient safety and quality in surgery
McCafferty, MH; Polk, HC
Surgical Clinics of North America, 87(4): 867-+.
Why good thoughts block better ones: The mechanism of the pernicious Einstellung (set) effect
Bilalic, M; McLeod, P; Gobet, F
Cognition, 108(3): 652-661.
Academic Emergency Medicine
Cognitive versus technical debriefing after simulation training
Bond, WF; Deitrick, LM; Eberhardt, M; Barr, GC; Kane, BG; Worrilow, CC; Arnold, DC; Croskerry, P
Academic Emergency Medicine, 13(3): 276-283.
Annals of Emergency Medicine
Chest pain: Physician perceptions and decisionmaking in a London emergency department
Farmer, SA; Higginson, IJ
Annals of Emergency Medicine, 48(1): 77-85.
Journal of Emergency Nursing
Know the plan, share the plan, review the risks: A method of structured communication for the emergency care setting
Salisbury, M; Hohenhaus, SM
Journal of Emergency Nursing, 34(1): 46-48.
Bmc Medical Informatics and Decision Making
Measurement properties of the Inventory of Cognitive Bias in Medicine (ICBM)
Sladek, RM; Phillips, PA; Bond, MJ
Bmc Medical Informatics and Decision Making, 8(): -.
Nursing Economics
The Neuropsychology of Good Leaders Making Dumb Mistakes
Kerfoot, KM
Nursing Economics, 27(2): 134-135.

Academic Medicine
Virtual Patients: ED-2 Band-Aid or Valuable Asset in the Learning Portfolio?
Tworek, J; Coderre, S; Wright, B; McLaughlin, K
Academic Medicine, 85(1): 155-158.
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Academic Medicine
Perspective: Uses and Misuses of Thresholds in Diagnostic Decision Making
Warner, JL; Najarian, RM; Tierney, LM
Academic Medicine, 85(3): 556-563.
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Academic Medicine
Using Simulation to Instruct Emergency Medicine Residents in Cognitive Forcing Strategies
Bond, WF; Deitrick, LM; Arnold, DC; Kostenbader, M; Barr, GC; Kimmel, SR; Worrilow, CC
Academic Medicine, 79(5): 438-446.

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Academic Medicine
Metacognitive Training to Reduce Diagnostic Errors: Ready for Prime Time?
Graber, M
Academic Medicine, 78(8): 781.

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Academic Medicine
Cognitive Underpinnings of Diagnostic Error
Gordon, R; Franklin, N
Academic Medicine, 78(8): 782.

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Critical Care Medicine
Clinicians' evaluation and management of mental health, substance abuse, and chronic pain conditions in the intensive care unit*
Broyles, LM; Colbert, AM; Tate, JA; Swigart, VA; Happ, MB
Critical Care Medicine, 36(1): 87-93.
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Journal of Psychiatric Practice®
Challenging the Established Diagnosis in Psychiatric Practice: Is It Worth It?
Journal of Psychiatric Practice®, 14(1): 67-72.
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Journal of Psychiatric Practice®
Biases in Medication Prescribing: The Case of Second-Generation Antipsychotics
Makhinson, M
Journal of Psychiatric Practice®, 16(1): 15-21.
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