Takeaway
To minimize common mistakes in diagnoses, clinicians must be mindful of cognitive and anchoring biases. Regularly seeking alternative explanations is one way to accomplish this.
Lifelong Learning in Clinical Excellence | November 26, 2024 | 4 min read
By Elizabeth Fracica, MD, MPH, Johns Hopkins Medicine
Serious diagnostic errors resulting in patient death or dismemberment are rare, (although of course they certainly do happen), in part because we’ve designed systems that make unacceptable errors acceptably rare. The converse is also true—benign errors are more common. This is due to incredible strides in the field of patient safety made over the past few decades. Major strategies for addressing diagnostic error include system factors engineering, engineering EHRs to be safer (for example best practice advisories and warning notifications when a potentially dangerous prescription has been ordered), OR checklists and time-outs to prevent wrong-site surgeries, and other interventions that reduce our reliance on imperfect human actors. With that said, as practicing physicians, we strive for excellence when caring for every patient, and there are some practical tips we can try to follow to both reduce the likelihood of a diagnostic error and lessen its impact on the patient-doctor relationship.
Tips to avoid diagnostic errors
In considering diagnostic errors that commonly occur at the physician level, we will focus on cognitive errors. The behavioral economist Daniel Kahneman famously described System 1 and System 2 thinking in his landmark text, “Thinking Fast and Slow,” where System 1 thinking is the fast, intuitive thinking we engage in to almost effortlessly address familiar questions, and System 2 thinking is the slow, effortful, conscious thought we engage in for unfamiliar or complex topics. We wouldn’t be able to get through our day if we relied solely on System 2 thinking, as it would be too slow and energetically expensive for the brain. However, over-reliance on the cognitive shortcuts used in System 1 thinking can lead us to inaccurate and sometimes harmful conclusions. The best way to reduce the risk of cognitive bias and its role in diagnostic error is to be aware of our biases and to routinely implement cognitive strategies to circumvent these vulnerabilities in our thinking
Common cognitive errors in medicine
Availability bias is the heuristic (or mental shortcut) that occurs when we make judgments about the likelihood of an event based on how easily we can recall recent examples of that event occurring. The problem with this strategy is that the frequency that something comes to mind is typically not an accurate representation of the real-world probability of this event occurring.
Anchoring bias occurs when we rely too heavily on information received up front and too little on information received later when making a judgement about the most likely diagnosis.
Confirmation bias is our tendency to consider information that confirms or supports our existing conceptualization as well as the tendency to ignore or less heavily weight information that counteracts our suspected diagnosis.
One strategy to try counteracting these biases is to implement a cognitive self-reflective pause when evaluating the most likely diagnosis. We can ask ourselves, “What are all the diagnoses I could be missing that should be on my differential? How would each of those diagnoses present, and what factors are present/absent that would support or refute each of those alternative hypotheses?” By systematically implementing this kind of reflective pause, we can try to reduce the risk of these biases leading to diagnostic error. With regard to anchoring bias, an initial suspected diagnosis is often made early in a hospital admission, but additional test results may change the most likely diagnosis. It’s important to continually reevaluate the most likely diagnosis based on all the test results together and on the patient’s clinical course.
Another good strategy is to try to develop an understanding of the most misdiagnosed diseases in your specialty and learn about the presenting symptoms that carry the greatest risk of misdiagnosis. Increased familiarity with these “red flag” atypical presenting symptoms can help raise suspicion for these uncommon presentations of commonly misdiagnosed conditions and thus help reduce diagnostic error.
Lastly, we should continue to strive for excellence in clinical knowledge. We can’t know everything, and we must try to avoid the pitfalls of overconfidence. We can readily use medical references, decision support tools, and engage in team-based care to fill in both recognized and unrecognized knowledge gaps.
What to say when diagnostic errors occur
A simple phrase to handle patient and family communication in the setting of a diagnostic error is: Gather, Disclose, Empathize, and Plan for the Future.
Gather as much information as you can about the circumstances surrounding the error. You want to have the best possible understanding of what happened, why the error may have occurred, how this affected the patient, what actions have already been taken, and what options are available to correct or mitigate the effects of the error moving forward.
Disclose the error to the patient and family and discuss what happened and the impact this had on the patient’s care, and the plan for correcting the error and mitigating any harm.
Empathize with the patient and family. Discuss that the error was unintentional and unplanned. Restate their feelings through reflective listening and reinforce that their feelings are appropriate, and that your team is here to support them. Apologize to the patient and family when appropriate.
Plan for the future: re-emphasize your dedication to ensuring that the patient receives the best care possible. Inform the patient and family that your team is doing everything possible to learn why the error happened. Explain how you will work vigilantly to ensure this doesn’t happen again. Discuss your plan to review the error with quality assurance team members and hospital leadership to learn from the error and put in place additional safeguards to ensure it doesn’t happen again.
Together, these tools can be used to further the already outstanding care each of you provides for our patients.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.