Diagnostic Decision-Making and Strategies to Improve Diagnosis

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A significant portion of diagnostic errors arises through cognitive errors resulting from inadequate knowledge, faulty data gathering, and/or faulty verification. Experts estimate that 75% of diagnostic failures can be attributed to clinician diagnostic thinking failure. The cognitive processes that underlie diagnostic thinking of clinicians are complex and intriguing, and it is imperative that clinicians acquire explicit appreciation and application of different cognitive approaches to make decisions better. A dual-process model that unifies many theories of decision-making has emerged as a promising template for understanding how clinicians think and judge efficiently in a diagnostic reasoning process. The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research. Suggested strategies to decrease diagnostic error incidence include increasing clinician's clinical expertise and avoiding inherent cognitive errors to make decisions better. Implementing Interventions focused solely on avoiding errors may work effectively for patient safety issues such as medication errors. Addressing cognitive errors, however, requires equal effort on expanding the individual clinician's expertise. Providing cognitive support to clinicians for robust diagnostic decision-making serves as the final strategic target for decreasing diagnostic errors. Clinical guidelines and algorithms offer another method for streamlining decision-making and decreasing likelihood of cognitive diagnostic errors. Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. While many suggested approaches exist, they are mostly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions are primarily suggestions and very few of them have been tested in the actual practice settings. Collaborative research effort is required to effectively address cognitive processing errors. Researchers in various areas, including patient safety/quality improvement, decision-making, and problem solving, must work together to make medical diagnosis more reliable.

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Case Description

A 12-day-old infant presented with vomiting and bloody stool. At 6 days old, he began vomiting, which was followed by irritability and diarrhea. He was switched to a different feeding formula, which did not help relieve the symptoms. Six days later, he began having bloody stools with mucus and periods of inconsolable crying. An abdominal radiograph showed bowel gas paucity in the right lower quadrant suggestive of intussusception. The infant was then transferred to a tertiary care hospital for

Bounded Rationality

To achieve the optimal clinical outcome, clinicians are expected to make expert medical decisions leading to the right diagnosis and to recommend the most appropriate treatment. Along with experience and dedication, clinicians are expected to have expertise in making decisions based on a considerable amount of scientific data and rapidly increasing medical knowledge. The rationality of decision-makers, however, is limited by the availability of the information, the individuals' cognitive

Cognitive Solutions to Improve Diagnostic Decisions

The identification and implementation of strategies for decreasing or preventing such diagnostic errors has become a growing area of interest and research as well. Graber et al.25 conducted a comprehensive review of cognitive interventions to reduce diagnostic errors along with the supporting evidence for each. Adapted from the proposed framework, we summarize the recommended strategies into three approaches (Table 2). The first area focuses on increasing clinician clinical expertise. The

Expand Clinical Expertise

Strategies designed to increase the knowledge and experience of a clinician offer great opportunities to improve diagnostic accuracy for medical trainees and practicing clinicians alike. To truly work at increasing knowledge in a given area, clinicians must be aware of their own areas of knowledge deficit. Actual patient encounters in daily practices, simulated patient interactions, knowledge self-assessments, and continuing medical education (CME) activities offer several mechanisms for

Avoid Cognitive Processing Errors to Make Decisions Better

Efforts focused on avoiding cognitive processing errors in clinical encounters can present a challenge for trainees and practicing clinicians alike. We will divide our attention on two specific areas of focus related to errors in diagnostic reasoning: improving System 1 and System 2 processes.

Reduce Cognitive Burdens Via Cognitive Aids

Providing clinicians with external cognitive support offers another valuable way to decrease the likelihood of diagnostic errors. The use of specialist consultants or “second opinions” can support the clinician in an unsure diagnostic or therapeutic encounter.1, 38 The help can come in the form of additional expertise, ability to “play devil's advocate” or simply a “fresh set of eyes” to look at the clinical situation in a new angle. The application of “second reading” in radiology may be

Conclusions

Addressing cognitive processing errors is undeniably the most challenging task in reducing diagnostic errors. Given increasing attention in the cognitive contributions to diagnostic error, a large number of approaches and strategies have been discussed. They are predominantly based on theories and sciences in cognitive psychology, decision-making, and education. The proposed interventions, however, are primarily suggestions, and very few of them have been proven effective in the actual practice

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