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News: Exercising Metacognition Makes the Difference in Diagnosis

Katz, Alissa

doi: 10.1097/01.EEM.0000475606.37190.7d


Cognitive errors aren't the patient's or computer's fault, but they are why it's critical for emergency physicians to incorporate metacognition into their decision-making process, said George Higgins III, MD, speaking at the recent Scientific Assembly of the American College of Emergency Physicians.

When an EP is stressed, it's even more critical to have the ability to think clearly and make the right decisions every time, he said. “Arriving at the diagnosis is the hard part, and the most important,” said Dr. Higgins, academic faculty in emergency medicine at Maine Medical Center and a professor at Tufts University School of Medicine.

Metacognition is “how we think, how we get to decisions, and how we get to impressions, and we [need to] step back and think about how we got there. And if we can do that in the clinical arena, we can make a big difference on mental error,” he said.

Endless types of cognitive diagnostic error plague emergency physicians, including diagnosis momentum, availability bias, and confirmation bias, which is searching for evidence that confirms a tentative diagnosis while de-emphasizing contrary evidence. And if those weren't enough, other errors are also anchoring and premature closure, overconfidence bias, and location bias, when the physical location of the patient influences a clinician's thinking. (Read more about location bias at

Dr. Higgins said the steps for exercising metacognition and avoiding cognitive error are:

  • Perception: Gather cues and clues, like vital signs and history, and listen and watch the patient openly. It is also key to reevaluate with regularity, which is possibly the best way to avoid errors, he said.
  • Hypothesis generation: Rank the clues and cues, and establish a short list of possible diagnoses for every body system. Make sure to leave the exam room and immediately construct a list of the most likely diagnosis and the top two can't-miss diagnoses.
  • Data collection/analysis: For each possible diagnosis, determine if confirmation requires a test.
  • Identify treatment threshold: Determine the threshold to treat after establishing the most likely unifying diagnosis.
  • Medical decision-making: Document decision-making before the patient leaves if he has any potentially dangerous condition, like chest pain, abdominal pain, or headache. “This often shines light on unresolved issues that were previously invisible to you,” Dr. Higgins said.

Following these steps is not the way everyone practices, although many physicians say they do, according to Dr. Higgins. “We quickly get to a diagnosis, we anchor on it, we undertest or overtest with tests that aren't valid. Then we fail to document what our thinking was. We don't know what's on the brains of these [patients and their families]. We can't just say, ‘It's x; we're going to do y. I'm the doctor.’ That's not acceptable anymore,” he said.

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