Advances in Health Sciences Education

, Volume 14, Supplement 1, pp 19–25 | Cite as

What makes diagnosis hard?

  • Robert L. Wears


This essay uses a case study to explore some of the reasons why understanding failures associated with diagnosis seems to have lagged behind the attention and understanding directed at failures in other aspects of healthcare (e.g., wrong patient/procedure, medication misadministration, etc). The goal is not to pose an alternative to many of the current ideas about problems in diagnosis, but rather to enrich the discussions.


Cognition Hindsight bias Joint cognitive systems Mis-diagnosis Sense-making Patient safety 


  1. Box, G. E. P. (1976). Science and statistics. Journal of the American Statistical Association, 71, 791–799.CrossRefGoogle Scholar
  2. Brehmer, B. (1987). Development of mental models for decision in technological systems. In J. Rasmussen, K. Duncan, & J. Leplat (Eds.), New technology and human error (pp. 111–120). Chichester, UK: Wiley.Google Scholar
  3. Brooks, L. R., LeBlanc, V. R., & Norman, G. R. (2000). On the difficulty of noticing obvious features in patient appearance. Psychological Science, 11(2), 112–117.CrossRefGoogle Scholar
  4. Croskerry, P., & Norman, G. (2008). Overconfidence in clinical decision making. The American Journal of Medicine, 121(5), S24–S29.CrossRefGoogle Scholar
  5. Evans, J. S. B. T. (2008). Dual-processing accounts of reasoning, judgment, and social cognition. Annual Review of Psychology, 59(1), 255–278.CrossRefGoogle Scholar
  6. Henriksen, K., & Kaplan, H. (2003). Hindsight bias, outcome knowledge and adaptive learning. Quality and Safety in Health Care, 12(Suppl 2), ii46–ii50.Google Scholar
  7. Hollnagel, E., & Woods, D. D. (2006). Joint cognitive systems: Foundations of cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis Group.Google Scholar
  8. Hutchins, E. (1996). Cognition in the wild. Cambridge, MA: MIT Press.Google Scholar
  9. Klein, G. (2008). Naturalistic decision making. Human Factors: The Journal of the Human Factors and Ergonomics Society, 50, 456–460.CrossRefGoogle Scholar
  10. Klein, G., Pliske, R., Crandall, B., & Woods, D. D. (2005). Problem detection. Cognition, Technology & Work, 7(1), 14–28.CrossRefGoogle Scholar
  11. Norman, G. R., & Brooks, L. R. (1997). The non-analytical basis of clinical reasoning. Advances in Health Sciences Education: Theory and Practice, 2(2), 173–184.CrossRefGoogle Scholar
  12. Norman, G., Young, M., & Brooks, L. (2007). Non-analytical models of clinical reasoning: The role of experience. Medical Education, 41(12), 1140–1145.Google Scholar
  13. Parasuraman, R., Sheridan, T. B., & Wickens, C. D. (2000). A model for types and levels of human interaction with automation. IEEE Transactions on Systems, Man and Cybernetics: Part A, 30(3), 286–297.CrossRefGoogle Scholar
  14. Raiffa, H. (1970). Decision analysis: Introductory Lectures on choices under uncertainty. Reading, MA: Addison-Wesley.Google Scholar
  15. Rasmussen, J. (1993). Diagnostic reasoning in action. IEEE Transactions on Systems, Man and Cybernetics, Part A, 23(4), 981–992.CrossRefGoogle Scholar
  16. Rittel, H. W. J., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155–169.CrossRefGoogle Scholar
  17. Rudolph, J. W., Morrison, J. B., & Carroll, J. S. (2009, in press). The dynamics of diagnosing: action-oriented problem solving in fast-paced, high-stakes settings. Academy of Management Review, 34(4).Google Scholar
  18. Vicente, K. J. (1999). Cognitive work analysis. Mahwah, NJ: Lawrence Erlbaum Associates.Google Scholar
  19. Weick, K. E. (1995). Sense making in organizations. Thousand Oaks, CA: Sage.Google Scholar
  20. Woods, D. D., & Hollnagel, E. (2006). Joint cognitive systems: Patterns in cognitive systems engineering. Boca Raton, FL: CRC Press/Taylor & Francis Group.Google Scholar

Copyright information

© Springer Science+Business Media B.V. 2009

Authors and Affiliations

  1. 1.Department of Emergency MedicineUniversity of Florida Health Science Center, JacksonvilleJacksonvilleUSA
  2. 2.Clinical Safety Research UnitImperial College LondonLondonUK

Personalised recommendations