Lessons in clinical reasoning ‒ pitfalls, myths, and pearls: a case of confusion, disequilibrium, and “picking at the air”

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Charles D. Magee ◽  
Andrew S. Parsons ◽  
Alexander S. Millard ◽  
Dario Torre
Keyword(s):  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Human Cognition ◽  
Case Presentation ◽  
Fishbone Diagram ◽  
Major Factors ◽  
Medication Changes ◽  
Incision Drainage

Abstract Objectives Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. Case presentation A 43-year-old female was brought to the emergency department with 4–5 days of confusion, disequilibrium resulting in several falls, and hallucinations. Further investigation revealed tachycardia, diaphoresis, mydriatic pupils, incomprehensible speech and she was seen picking at the air. Given multiple recent medication changes, there was initial concern for serotonin syndrome vs. an anticholinergic toxidrome. She then developed a fever, marked leukocytosis, and worsening encephalopathy. She underwent lumbar puncture and aspiration of an identified left ankle effusion. Methicillin sensitive staph aureus (MSSA) grew from blood, joint, and cerebrospinal fluid cultures within 18 h. She improved with antibiotics and incision, drainage, and washout of her ankle by orthopedic surgery. Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts, this case underscores how multiple cognitive biases can cascade sequentially, skewing clinical reasoning toward erroneous conclusions and driving potentially inappropriate testing and treatment. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of structured reflection, a tool to promote metacognitive analysis, and the application of knowledge organization tools such as illness scripts to navigate these cognitive biases.

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Vita Jaspan ◽  
Verity Schaye ◽  
Andrew S. Parsons ◽  
David Kudlowitz
Keyword(s):  
Acute Pancreatitis ◽  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
First Episode ◽  
Gut Flora ◽  
Case Presentation ◽  
Early Hypothesis ◽  
Elevated Transaminases

Abstract Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

scholarly journals Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of chest pain and shortness of breath

Diagnosis ◽  
2019 ◽  
Vol 6 (4) ◽  
pp. 387-392
Author(s):  
McCall Walker ◽  
Karen M. Warburton ◽  
Joseph Rencic ◽  
Andrew S. Parsons
Keyword(s):  
Chest Pain ◽  
Clinical Reasoning ◽  
Elevated Serum ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Human Cognition ◽  
Shortness Of Breath ◽  
Coronary Syndrome ◽  
Premature Closure ◽  
Submassive Pulmonary Embolism

Abstract Background Defects in human cognition commonly result in clinical reasoning failures that can lead to diagnostic errors. A metacognitive structured reflection on what clinical findings fit and/or do not fit with likely and “can’t miss” diagnoses may reduce such errors. Case presentation A 57-year-old man was sent to the emergency department from clinic with chest pain, severe shortness of breath, weakness, and cold sweats. Further investigation revealed multiple risk factors for coronary artery disease, sudden onset of exertional dyspnea, and chest pain that incompletely resolved with rest, mild tachycardia and hypoxia, an abnormal electrocardiogram (ECG), elevated serum cardiac biomarkers, and elevated B-type natriuretic peptide (BNP) in the absence of left-sided heart failure. He was treated for acute coronary syndrome (ACS), discharged, and quickly returned with worsening symptoms that eventually led to a diagnosis of submassive pulmonary embolism (PE). Conclusions Through integrated commentary on the diagnostic reasoning process from clinical reasoning experts at two institutions, this case underscores the importance of frequent assessment of fit along with explicit explanation of dissonant features in order to avoid premature closure and diagnostic error. A fishbone diagram is provided to visually demonstrate the major factors that contributed to the diagnostic error. A case discussant describes the importance of diagnostic schema as an analytic reasoning strategy to assist in the creation of a differential diagnosis, problem representation to summarize updated findings, a Popperian analytic approach of attempting to falsify less-likely hypotheses, and matching pertinent positives and negatives to previously learned illness scripts. Finally, this case provides clinical teaching points in addition to a pitfall, myth, and pearl specific to premature closure.

Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Martin A. Schaller-Paule ◽  
Helmuth Steinmetz ◽  
Friederike S. Vollmer ◽  
Melissa Plesac ◽  
Felix Wicke ◽  
...  
Keyword(s):  
Patient Safety ◽  
Clinical Reasoning ◽  
Data Gathering ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Care Physician ◽  
Diagnostic Process ◽  
Myasthenic Crisis ◽  
Hospital Organization ◽  
Substantial Impact

Abstract Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

scholarly journals Development and evaluation of a clinical reasoning curriculum as part of an Internal Medicine Residency Program

Diagnosis ◽  
2019 ◽  
Vol 6 (2) ◽  
pp. 115-119 ◽  
Author(s):  
Shwetha Iyer ◽  
Erin Goss ◽  
Casey Browder ◽  
Gerald Paccione ◽  
Julia Arnsten
Keyword(s):  
Internal Medicine ◽  
Clinical Reasoning ◽  
Residency Program ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Internal Medicine Residency ◽  
Case Vignette ◽  
Internal Medicine Residency Program ◽  
Reasoning Skills ◽  
Clinical Reasoning Skills

Abstract Background Errors in medicine are common and often tied to diagnosis. Educating physicians about the science of cognitive decision-making, especially during medical school and residency when trainees are still forming clinical habits, may enhance awareness of individual cognitive biases and has the potential to reduce diagnostic errors and improve patient safety. Methods The authors aimed to develop, implement and evaluate a clinical reasoning curriculum for Internal Medicine residents. The authors developed and delivered a clinical reasoning curriculum to 47 PGY2 residents in an Internal Medicine Residency Program at a large urban hospital. The clinical reasoning curriculum consists of six to seven sessions with the specific aims of: (1) educating residents on cognitive steps and reasoning strategies used in clinical reasoning; (2) acknowledging the pitfalls of clinical reasoning and learning how cognitive biases can lead to clinical errors; (3) expanding differential diagnostic ability and developing illness scripts that incorporate discrete clinical prediction rules; and (4) providing opportunities for residents to reflect on their own clinical reasoning (also known as metacognition). Results Forty-seven PGY2 residents participated in the curriculum (2013–2016). Self-assessed comfort in recognizing and applying clinical reasoning skills increased in 15 of 15 domains (p < 0.05 for each). Resident mean scores on the knowledge assessment improved from 58% pre-curriculum to 81% post curriculum (p = 0.002). Conclusions A case vignette-based clinical reasoning curriculum can effectively increase residents’ knowledge of clinical reasoning concepts and improve residents’ self-assessed comfort in recognizing and applying clinical reasoning skills.

scholarly journals P139: How available is availability bias? Examining factors that influence diagnostic error

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S106-S106
Author(s):  
J. Sherbino ◽  
S. Monteiro ◽  
J. Ilgen ◽  
E. Hayden ◽  
E. Howey ◽  
...  
Keyword(s):  
Medical Students ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Test Case ◽  
Test Cases ◽  
Contributing Factors ◽  
Current Case ◽  
Availability Bias ◽  
Category Priming

Introduction: Cognitive bias is often cited as an explanation for diagnostic errors. Of the numerous cognitive biases currently discussed in the literature, availability bias, defined as the current case reminds you of a recent similar example is most well-known. Despite the ubiquity of cognitive biases in medical and popular literature, there is surprisingly little evidence to substantiate these claims. The present study sought to measure the influence of availability bias and identify contributing factors that may increase susceptibility to the influence of a recent similar case. Methods: To investigate the role of prior examples and category priming on diagnostic error at different levels of expertise, we devised a 2 phase experiment. The experimental intervention was in a validation phase preceding the test, where participants were asked to verify a diagnosis which was either i) representative of Diagnosis A, and similar to a test case, ii) representative of Diagnosis A and dissimilar to a test case, iii) representative of Diagnosis B and similar to a test case. The test phase consisted of 8 written cases, each with two approximately equally likely diagnoses(A or B). Each participant verified 2 cases from each condition, for a total of 6. They then diagnosed all 8 test cases; the remaining 2 test cases had no prior example. All cases were counterbalanced across conditions. Comparison between Condition i) and ii) and no prior showed effect of prior exemplar; comparison between iii) and no prior showed effect of category priming. Because cases were designed so that both Diagnosis A and B were likely, overall accuracy was measured as the sum of proportion of cases in which either was selected. Subjects were emergency medicine staff (n=40), residents (n=39) and medical students (n=32) from McMaster University, University of Washington, and Harvard Medical School. Results: Overall, staff had an accuracy (A + B) of 98%, residents 98% and students 85% (F=35.6,p<.0001). For residents and staff there was no effect of condition (all mean accuracies 97% to 100%); for students there was a clear effect of category priming, with accuracy of 84% for i), 87% for ii) and 94% for iii) but only 73% for the no prime condition (Interaction F= 3.54, p<.002) Conclusion: Although prior research has shown substantial biasing effects of availability, primarily in cases requiring visual diagnosis, the present study has shown such effects only for novices (medical students). Possible explanations need to be explored. Nevertheless, our study shows that with increasing expertise, availability may not be a source of error.

scholarly journals The COVID trap: pediatric diagnostic errors in a pandemic world

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Yasaman Fatemi ◽  
Susan Coffin
Keyword(s):  
Care Delivery ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Cognitive Factors ◽  
Diagnostic Process ◽  
Case Presentation ◽  
Medical Environment ◽  
Early Phases ◽  
Specific Influence ◽  
Missed Diagnoses

Abstract Objectives The COVID-19 pandemic has introduced strains in the diagnostic process through uncertainty in diagnosis, changes to usual clinical processes, and introduction of a unique social context of altered health care delivery and fear of the medical environment. These challenges created a context ripe for diagnostic error involving both systems and cognitive factors. Case presentation We present a series of three pediatric cases presenting to care during the early phases of the COVID-19 pandemic that highlight the heightened potential for diagnostic errors in the pandemic context with particular focus on the interplay of systems and cognitive factors leading to delayed and missed diagnoses. These cases illustrate the particular power of availability bias, diagnostic momentum, and premature closure in the diagnostic process. Conclusions Through integrated commentary and a fishbone analysis of the cognitive and systems factors at play, these three cases emphasize the specific influence of the COVID-19 pandemic on pediatric patients.

Teaching and Assessing Critical Thinking and Clinical Reasoning Skills in Medical Education

2019 ◽  
pp. 213-233
Author(s):  
Md. Anwarul Azim Majumder ◽  
Bidyadhar Sa ◽  
Fahad Abdullah Alateeq ◽  
Sayeeda Rahman
Keyword(s):  
Medical Education ◽  
Critical Thinking ◽  
Clinical Reasoning ◽  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Higher Order Thinking ◽  
Recent Trends ◽  
Reasoning Skills ◽  
Clinical Reasoning Skills ◽  
And Training

In recent years, there has been more emphasis on developing higher order thinking (e.g., critical thinking and clinical reasoning) processes to tackle the recent trends and challenges in medical education. Critical thinking and clinical reasoning are considered to be the cornerstones for teaching and training tomorrow's doctors. Lack of training of critical thinking and clinical reasoning in medical curricula causes medical students and physicians to use cognitive biases in problem solving which ultimately leads to diagnostic errors later in their professional practice. Moreover, there is no consensus on the most effective teaching model to teach the critical thinking and clinical reasoning skills and even the skill is not effectively tested in medical schools. This chapter will focus on concepts, contemporary theories, implications, issues and challenges, characteristics, various steps, teaching models and strategies, measuring and intervention tools, and assessment modalities of critical thinking and clinical reasoning in medical education settings.

Use of a novel, modified fishbone diagram to analyze diagnostic errors

Diagnosis ◽  
2014 ◽  
Vol 1 (2) ◽  
pp. 167-171 ◽  
Author(s):  
James B. Reilly ◽  
Jennifer S. Myers ◽  
Doug Salvador ◽  
Robert L. Trowbridge
Keyword(s):  
Patient Safety ◽  
Medical Errors ◽  
Diagnostic Errors ◽  
Diagnostic Error ◽  
Root Cause ◽  
Medical Centers ◽  
Cognitive Framework ◽  
Fishbone Diagram ◽  
Complex Events ◽  
Individual Cognition

AbstractDiagnostic errors comprise a critical subset of medical errors and often stem from errors in individual cognition. While traditional patient safety methods for dissecting medical errors focus on faulty systems, such methods are often less useful in cases of diagnostic error, and a broader cognitive framework is needed to ensure a comprehensive analysis of these complex events. The fishbone diagram is a widely utilized patient safety tool that helps to facilitate root cause analysis discussions. This tool was expanded by the authors to reflect the contributions of both systems and individual cognitive errors to diagnostic errors. We describe how two medical centers have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets the patient safety and educational needs of their respective institutions.

Learning from tragedy: the Julia Berg story

Diagnosis ◽  
2018 ◽  
Vol 5 (4) ◽  
pp. 257-266
Author(s):  
Mark L. Graber ◽  
Dan Berg ◽  
Welcome Jerde ◽  
Phillip Kibort ◽  
Andrew P.J. Olson ◽  
...  
Keyword(s):  
Cognitive Biases ◽  
Correct Diagnosis ◽  
Diagnostic Errors ◽  
Acalculous Cholecystitis ◽  
Liver Function Tests ◽  
Diagnostic Error ◽  
Epstein Barr Virus Infection ◽  
Barr Virus ◽  
Presenting Symptoms ◽  
Epstein Barr

Abstract This is a case report involving diagnostic errors that resulted in the death of a 15-year-old girl, and commentaries on the case from her parents and involved providers. Julia Berg presented with fatigue, fevers, sore throat and right sided flank pain. Based on a computed tomography (CT) scan that identified an abnormal-appearing gall bladder, and markedly elevated bilirubin and “liver function tests”, she was hospitalized and ultimately underwent surgery for suspected cholecystitis and/or cholangitis. Julia died of unexplained post-operative complications. Her autopsy, and additional testing, suggested that the correct diagnosis was Epstein-Barr virus infection with acalculous cholecystitis. The correct diagnosis might have been considered had more attention been paid to her presenting symptoms, and a striking degree of lymphocytosis that was repeatedly demonstrated. The case illustrates how cognitive “biases” can contribute to harm from diagnostic error. The case has profoundly impacted the involved healthcare organization, and Julia’s parents have become leaders in helping advance awareness and education about diagnostic error and its prevention.

Re-thinking morbidity and mortality

Diagnosis ◽  
2020 ◽  
Vol 0 (0) ◽  
Author(s):  
Sumner Abraham ◽  
Andrew Parsons ◽  
Brian Uthlaut ◽  
Peggy Plews-Ogan
Keyword(s):  
Cognitive Biases ◽  
Diagnostic Errors ◽  
Dual Process ◽  
Morbidity And Mortality ◽  
Dual Process Theory ◽  
Habits Of Mind ◽  
Thought Processes ◽  
University Of Virginia ◽  
Self Reflection ◽  
The University

AbstractDespite the breadth of patient safety initiatives, physicians talking about their mistakes to other physicians is a difficult thing to do. This difficulty may be exacerbated by a limited exposure to how to analyze and discuss mistakes and respond in a productive way. At the University of Virginia, we recognized the importance of understanding cognitive biases for residents in both their clinical and personal professional development. We re-designed our resident led morbidity and mortality (M&M) conference using a model that integrates dual-process theory and metacognition to promote informed reflection and analysis of cognitive diagnostic errors. We believe that structuring M&M in this way builds a culture that encourages reflection together to learn our most difficult diagnostic errors and to engage in where our thought processes went wrong. In slowly building this culture, we hope to inoculate residents with the habits of mind that can best protect them from harmful biases in their clinical reasoning while instilling a culture of self-reflection.

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