Acta Diabetologica

, Volume 53, Issue 2, pp 169–175 | Cite as

“First, know thyself”: cognition and error in medicine

  • Fabrizio Elia
  • Franco Aprà
  • Andrea Verhovez
  • Vincenzo Crupi
Review Article

Abstract

Although error is an integral part of the world of medicine, physicians have always been little inclined to take into account their own mistakes and the extraordinary technological progress observed in the last decades does not seem to have resulted in a significant reduction in the percentage of diagnostic errors. The failure in the reduction in diagnostic errors, notwithstanding the considerable investment in human and economic resources, has paved the way to new strategies which were made available by the development of cognitive psychology, the branch of psychology that aims at understanding the mechanisms of human reasoning. This new approach led us to realize that we are not fully rational agents able to take decisions on the basis of logical and probabilistically appropriate evaluations. In us, two different and mostly independent modes of reasoning coexist: a fast or non-analytical reasoning, which tends to be largely automatic and fast-reactive, and a slow or analytical reasoning, which permits to give rationally founded answers. One of the features of the fast mode of reasoning is the employment of standardized rules, termed “heuristics.” Heuristics lead physicians to correct choices in a large percentage of cases. Unfortunately, cases exist wherein the heuristic triggered fails to fit the target problem, so that the fast mode of reasoning can lead us to unreflectively perform actions exposing us and others to variable degrees of risk. Cognitive errors arise as a result of these cases. Our review illustrates how cognitive errors can cause diagnostic problems in clinical practice.

Keywords

Diagnostic errors Decision making Diagnosis Medical errors 

References

  1. 1.
    Kohn LTC, Donaldson JM, Molla S (eds) (2000) To err is human: building a safer health system. National Academy Press, WashingtonGoogle Scholar
  2. 2.
    Wu AW, Folkman S, McPhee SJ, Lo B (1991) Do house officers learn from their mistakes? JAMA 265:2089–2094CrossRefPubMedGoogle Scholar
  3. 3.
    Blendon RJ, DesRoches CM, Brodie M, Benson JM, Rosen AB, Schneider E, Altman DE, Zapert K, Herrmann MJ, Steffenson AE (2002) Views of practicing physicians and the public on medical errors. N Engl J Med 347:1933–1940CrossRefPubMedGoogle Scholar
  4. 4.
    Stripe SC, Best LG, Cole-Harding S, Fifield B, Talebdoost F (2006) Aviation model cognitive risk factors applied to medical malpractice cases. J Am Board Fam Med 19:627–632CrossRefPubMedGoogle Scholar
  5. 5.
    Gawande A (2009) The Checklist manifesto—how to get things right. Metropolitan Books, New YorkGoogle Scholar
  6. 6.
    Ely JW, Graber ML, Croskerry P (2011) Checklists to reduce diagnostic errors. Acad Med 86:307–313CrossRefPubMedGoogle Scholar
  7. 7.
    Mazur DJ (2012) A history of evidence in medical decisions: from the diagnostic sign to Bayesian inference. Med Decis Mak 32:227–231CrossRefGoogle Scholar
  8. 8.
    Porta M (2014) Acta Diabetologica is 50 and well: long live Acta! Acta Diabetol 51:1–3CrossRefPubMedGoogle Scholar
  9. 9.
    Elstein AS (2009) Thinking about diagnostic thinking: a 30 year perspective. Adv Health Sci Educ 14:7–18CrossRefGoogle Scholar
  10. 10.
    Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M (1983) The value of the autopsy in three medical eras. N Engl J Med 308:1000–1005CrossRefPubMedGoogle Scholar
  11. 11.
    Carvalho FM, Widmer MR, Cruz M, Palomo V, Cruz C (1991) Clinical diagnosis versus autopsy. Bull Pan Am Health Organ 25:41–46PubMedGoogle Scholar
  12. 12.
    Poli L, Pich A, Zanocchi M, Fonte G, Bo M, Fabris F (1993) Autopsy and multiple pathology in the elderly. Gerontology 39:55–63CrossRefPubMedGoogle Scholar
  13. 13.
    Veress B, Alafuzoff I (1994) A retrospective analysis of clinical diagnoses and autopsy findings in 3,042 cases during two different time periods. Hum Pathol 25:140–145CrossRefPubMedGoogle Scholar
  14. 14.
    Kirch W, Schafii C (1996) Misdiagnosis at a university hospital in 4 medical eras. Medicine (Baltimore) 75:29–40CrossRefGoogle Scholar
  15. 15.
    Kahneman D (2011) Thinking fast and slow. Macmillan, New YorkGoogle Scholar
  16. 16.
    Marcum JA (2012) An integrated model of clinical reasoning: dual-process theory of cognition and metacognition. J Eval Clin Pract 18:954–961CrossRefPubMedGoogle Scholar
  17. 17.
    Croskerry P (2009) Clinical cognition and diagnostic error: applications of a dual process theory of reasoning. Adv Health Sci Educ Theory Pract 14:27–35CrossRefPubMedGoogle Scholar
  18. 18.
    Goel V, Dolan RJ (2003) Explaining modulation of reasoning by belief. Cognition 87:B11–B22CrossRefPubMedGoogle Scholar
  19. 19.
    Marewski JN, Gigerenzer G (2012) Heuristic decision making in medicine. Dialogues Clin Neurosci 14:77–89PubMedPubMedCentralGoogle Scholar
  20. 20.
    Gigerenzer G (2008) Gut feelings: the intelligence of the unconscious. Viking Press, New YorkGoogle Scholar
  21. 21.
    Gladwell M (2005) Blink: The power of thinking without thinking. Little, Brown and Co, New YorkGoogle Scholar
  22. 22.
    Wegwarth O, Gaissmaier W, Gigerenzer G (2009) Smart strategies for doctors and doctors-in-training: heuristics in medicine. Med Educ 43:721–728CrossRefPubMedGoogle Scholar
  23. 23.
    Kahneman D, Frederick S (2002) Representativeness revisited: attribute substitution in intuitive judgment. In: Gilovich T, Griffin DW, Kahneman D (eds) Heuristics and biases. Cambridge University Press, New York, pp 49–81Google Scholar
  24. 24.
    Taleb NN (2010) The black swan: the impact of the highly improbable. Random House, New YorkGoogle Scholar
  25. 25.
    Reason J (1990) Human error. Cambridge University Press, New YorkCrossRefGoogle Scholar
  26. 26.
    Rittel HWJ, Webber MM (1973) Dilemmas in a general theory of planning. Policy Sci 4:155–169CrossRefGoogle Scholar
  27. 27.
    Wears RL (2009) What makes diagnosis hard? Adv Health Sci Educ Theory Pract 14(Suppl 1):19–25CrossRefPubMedGoogle Scholar
  28. 28.
    Fargen KM, Friedman WA (2014) The science of medical decision making: neurosurgery, errors, and personal cognitive strategies for improving quality of care. World Neurosurg 82:21–29CrossRefGoogle Scholar
  29. 29.
    Vick A, Estrada CA, Rodriguez JM (2013) Clinical reasoning for the infectious disease specialist: a primer to recognize cognitive biases. Clin Infect Dis 57:573–578CrossRefPubMedGoogle Scholar
  30. 30.
    Vickrey BG, Samuels MA, Ropper AH (2010) How neurologists think: a cognitive psychology perspective on missed diagnoses. Ann Neurol 67:425–433CrossRefPubMedGoogle Scholar
  31. 31.
    Dunbar M, Helms SE, Brodell RT (2013) Reducing cognitive errors in dermatology: can anything be done? J Am Acad Dermatol 69:810–813CrossRefPubMedGoogle Scholar
  32. 32.
    Stiegler MP, Ruskin KJ (2012) Decision-making and safety in anesthesiology. Curr Opin Anaesthesiol 25:724–729PubMedGoogle Scholar
  33. 33.
    Fandel TM, Pfnur M, Schafer SC, Bacchetti P, Mast FW, Corinth C, Ansorge M, Melchior SW, Thüroff JW, Kirkpatrick CJ, Lehr HA (2008) Do we truly see what we think we see? The role of cognitive bias in pathological interpretation. J Pathol 216:193–200CrossRefPubMedGoogle Scholar
  34. 34.
    Croskerry P (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 78:775–780CrossRefPubMedGoogle Scholar
  35. 35.
    Phua DH, Tan NC (2013) Cognitive aspect of diagnostic errors. Ann Acad Med Singap 42:33–41PubMedGoogle Scholar
  36. 36.
    Ogdie AR, Reilly JB, Pang WG, Keddem S, Barg FK, Von Feldt JM, Myers JS (2012) Seen through their eyes: residents’ reflections on the cognitive and contextual components of diagnostic errors in medicine. Acad Med 87:1361–1367CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Riva P, Rusconi P, Montali L, Cherubini P (2011) The influence of anchoring on pain judgment. J Pain Symptom Manag 42:265–277CrossRefGoogle Scholar
  38. 38.
    American Child Health Association Research Division (1934) Physical defects: the pathway to correction. American Child Health Association, New YorkGoogle Scholar
  39. 39.
    Lau AY, Coiera EW (2007) Do people experience cognitive biases while searching for information? J Am Med Inform Assoc 14:599–608CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Crupi V (2013) Confirmation. The Stanford encyclopedia of philosophy. EN Zalta (ed) http://plato.stanford.edu/entries/confirmation/
  41. 41.
    Pines JM (2006) Profiles in patient safety: confirmation bias in emergency medicine. Acad Emerg Med 13:90–94CrossRefPubMedGoogle Scholar
  42. 42.
    Self WH, Courtney DM, McNaughton CD, Wunderink RG, Kline JA (2013) High discordance of chest X-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia. Am J Emerg Med 31:401–405CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, Schmidt HG (2010) Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA 304:1198–1203CrossRefPubMedGoogle Scholar
  44. 44.
    Brezis M, Halpern-Reichert D, Schwaber MJ (2004) Mass media-induced availability bias in the clinical suspicion of West Nile fever. Ann Intern Med 140:234–235CrossRefPubMedGoogle Scholar
  45. 45.
    Schmidt HG, Mamede S, van den Berge K, van Gog T, van Saase JL, Rikers RM (2014) Exposure to media information about a disease can cause doctors to misdiagnose similar-looking clinical cases. Acad Med 89:285–291CrossRefPubMedGoogle Scholar
  46. 46.
    Ansher C, Ariely D, Nagler A, Rudd M, Schwartz J, Shah A (2014) Better medicine by default. Med Decis Mak 34:147–158CrossRefGoogle Scholar
  47. 47.
    Dumas F, Gonzalez M, Girotto V, Pascal C, Botton J-F, Crupi V (2012) The context of available options affects healthcare decisions: a generalization study. Med Decis Mak 32:815–819CrossRefGoogle Scholar
  48. 48.
    Sternbach G (2012) The phantom spider and other myths. J Emerg Med 42:457–458CrossRefPubMedGoogle Scholar
  49. 49.
    Perneger TV, Agoritsas T (2011) Doctors and patients’ susceptibility to framing bias: a randomized trial. J Gen Intern Med 26:1411–1417CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Bobbio M, Demichelis B, Giustetto G (1994) Completeness of reporting trial results: effect of physicians’ willingness to prescribe. Lancet 343:1209–1211CrossRefPubMedGoogle Scholar
  51. 51.
    McCabe DP, Castel AD (2008) Seeing is believing: the effect of brain images on judgments of scientific reasoning. Cognition 107:343–352CrossRefPubMedGoogle Scholar
  52. 52.
    Ashman CJ, Yu JS, Wolfman D (2000) Satisfaction of search in osteoradiology. AJR Am J Roentgenol 175:541–544CrossRefPubMedGoogle Scholar
  53. 53.
    Berbaum KS, Schartz KM, Caldwell RT, Madsen MT, Thompson BH, Mullan BF, Ellingson AN, Franken EA Jr (2013) Satisfaction of search from detection of pulmonary nodules in computed tomography of the chest. Acad Radiol 20:194–201CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Neira MI, Sánchez J, Moreno I, Chiaraviglio A, Rayo A, Gutiérrez J, Erice A (2006) Occam can be wrong: a young man with lumbar pain and acute weakness of the legs. Lancet 367:540CrossRefPubMedGoogle Scholar
  55. 55.
    Elia F, Pagnozzi F, Laface B, Aprà F, Roccatello D (2013) A victim of the Occam’s razor. Intern Emerg Med 8:767–768CrossRefPubMedGoogle Scholar
  56. 56.
    Caplan RA, Posner KL, Cheney FW (1991) Effect of outcome on physicians’ judgments of appropriateness of care. JAMA 265:1957–1960CrossRefPubMedGoogle Scholar
  57. 57.
    Mazzocco K, Cherubini P (2010) The effect of outcome information on health professionals’ spontaneous learning. Med Educ 44:962–968CrossRefPubMedGoogle Scholar
  58. 58.
    Croskerry P, Norman G (2008) Overconfidence in clinical decision making. Am J Med 121:S24–S29CrossRefPubMedGoogle Scholar
  59. 59.
    Berner ES, Graber ML (2008) Overconfidence as a cause of diagnostic error in medicine. Am J Med 121:S2–S23CrossRefPubMedGoogle Scholar
  60. 60.
    Arkes H (2013) The consequences of the hindsight bias in medical decision making. Curr Dir Psychol Sci 22:356–360CrossRefGoogle Scholar
  61. 61.
    Deskin WC, Hoye RE (2004) Another look at medical error. J Surg Oncol 88:122–129CrossRefPubMedGoogle Scholar
  62. 62.
    Kahneman D (2003) Maps of bounded rationality: psychology for behavioral economics. Am Econ Rev 93:1449–1475CrossRefGoogle Scholar
  63. 63.
    Reyna V (2008) Theories of medical decision making and health: an evidence-based approach. Med Decis Mak 28:829–833CrossRefGoogle Scholar
  64. 64.
    Schwartz A (2011) Medical decision making and medical education: challenges and opportunities. Perspect Biol Med 54:68–74CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Italia 2015

Authors and Affiliations

  • Fabrizio Elia
    • 1
  • Franco Aprà
    • 1
  • Andrea Verhovez
    • 1
  • Vincenzo Crupi
    • 2
  1. 1.High Dependency UnitSan Giovanni Bosco HospitalTurinItaly
  2. 2.Department of Philosophy and Education, Center for Logic, Language, and CognitionUniversity of TurinTurinItaly

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