A useful article by Canadian Pat Croskerry, summarises some recent important, relevant and practical information that can help with diagnostic and other decisions.
In our lives and work we repeatedly make quick judgments and decisions – that is not only a good thing but essential to ordinary and professional life. A lot of very good research over recent years has looked at the nature of this intuitive and near intuitive thinking – how it happens and how it can go wrong. Our amazing ability to make decisions and judgments quickly is associated with a cognitive process which is largely unconscious and autonomous involving ‘heuristics’. An heuristic is any approach to problem solving that uses a practical method that is not guaranteed to be optimal, perfect or rational but is nevertheless sufficient for reaching an immediate, short term goal or approximation.
There are positive heuristics which can safeguard against bias or error. These are often the product of repeated practice and ingrained habit. An example is in the proverb: ‘measure twice, cut once’. Such heuristics are often based on advice or example from teachers, supervisors or other clinicians when we are learning our trade or profession and also often based on experience. Of course, this learning and development of heuristics should continue throughout our lives and professional careers.
And there are negative heuristics where these rapid decision making processes can lead to unfortunate outcomes. Some examples:
• Anchoring: relying too much on pre-existing information or the first information available.
• Premature closure: accepting a diagnosis or understanding before there is sufficient evidence to support it. Jumping to conclusions.
• Availability: judgment based on what is easiest to bring to mind.
Croskerry suggests some strategies to improve diagnostic judgment. I have expanded these to apply to other clinical judgments.
1. Establish (as part of the curriculum) in training and education, awareness of the ways cognition works.
2. Coach critical thinking during education, training, supervision.
3. Make the work environment more conducive to sound thinking by reducing fatigue, cognitive overload, sleep deprivation, stress, burnout and negative workplace experiences such as bullying.
4. Circumvent Type I (intuitive) distortion through mindfulness, reflection, self-awareness and education/training (see strategy 1).
5. Expand individual expertise by developing more flexibility and innovation in problem solving especially when dealing with atypical, rare or novel situations.
6. Promote team cognition through interdisciplinary interaction, team discussion in a setting where any team member can feel comfortable about speaking up.
7. Mitigate judgment and decision-making failure by developing governance, clinical procedures and other measures to reduce the risks of intuitive Type I reasoning, protected by analytic Type II reasoning where necessary. In relation to diagnostic decision making Croskerry suggests clinical maxims such as “always develop a differential diagnosis”, “rule out worst-case scenario”, “until proved otherwise” and “consider the opposite”.
The Rational Diagnostician & Achieving Diagnostic Excellence. Pat Croskerry. JAMA Published online Jan 7, 2022
The Rational Diagnostician and Achieving Diagnostic Excellence | Medical Education and Training | JAMA | JAMA Network