Recognizing Clinical

Reasoning Errors
Zayadi Zainuddin, MD, M.Med.Ed
Medical Program Study
University of Bengkulu
 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

Skill Knowledge
 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

Differential Diagnosis
Generation

Information
Diagnosis Refinement
gathering

Diagnosis Verification
 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 Probability
Unpacking Aggregate bias
Availability Base-rate neglect
Anchoring Gender bias
Premature closure Gamblers fallacy
System Posterior probability
Diagnosis momentum error
Feedback sanction
Croskerry, 2003
Triage cueing
 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
 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
Unpacking
Availability
Differential Diagnosis
Generation
Anchoring

Information
Diagnosis Refinement
gathering Premature
closure

Diagnosis Verification
 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)
 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
Gamblers 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
Didnt meet criteria, but I(aggregate)
Rare diagnoses high on list, increased
testing (base-rate neglect)
Comments about probability (Gamblers
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?