Annals of Emergency Medicine
Volume 41, Issue 1 , Pages 121-122, January 2003

Thinking about thinking☆

Emergency Department, Albert Einstein College of Medicine, Bronx, NY.

Address for correspondence: E. John Gallagher, MD, Emergency Department, Montefiore Medical Center, Bronx, NY 10467-2490; 718-920-7459, fax 718-798-0730; E-mail Jgallagh@montefiore.org.

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Editor ’s note: This new feature, “Brief Commentary,” is discussion focusing on 1 or 2 key points about the study on which it is written—strengths, weaknesses, where it fits in the context of other studies, controversies, how it should or should not change our clinical practice, or even how it illustrates some important principle of science or methodology. It is not meant to be as long or complete as an “Editorial,” but more of a focused comment that does not attempt to be a complete discussion of a paper. [Ann Emerg Med. 2003;41:121-122.]

See related article, p. 110 .

Medical error is among the top 10 causes of death in the United States.1 Not surprisingly, the emergency department has been identified as an area prone to medical error,2 particularly diagnostic error.3 Preliminary data suggest that erroneous diagnoses are among the most clinically consequential and potentially preventable of errors in emergency practice.4, 5

In this issue of Annals , Croskerry6 draws on the cognitive sciences to ask and answer 3 basic questions pertinent to diagnostic error in emergency medicine. Although the taxonomy is sometimes formidable, the premises of the argument are sound, the reasoning logical, the conclusions persuasive, and the information clinically important.

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How can I minimize errors in diagnosis? 

Because formulation of a working diagnosis is the product of clinical thinking, it logically follows that most diagnostic errors are cognitive ones, that is, errors in thinking. By extension of this logic, improved understanding of clinical thought processes should identify ways to reduce diagnostic error.

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How can I obtain a better understanding of my clinical thinking? 

Cognitive science suggests that this can be achieved through “metacognition,” that is, “thinking about thinking.”7 This is accomplished by stepping back from the diagnostic process for a moment to retrace and tease apart the logic that led one to a given set of diagnostic possibilities. Information gleaned from such a dissection can then be used to develop conscious activities, known as “cognitive forcing strategies,” that is, ways of actively monitoring and modifying decisionmaking through insight into one's clinical thinking. Building these strategies into the diagnostic reasoning process then “forces” critical examination and reexamination of one's clinical thinking, leading to reduction of medical error through a kind of mandatory mindfulness.8

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How can I devise cognitive forcing strategies to help me minimize diagnostic error? 

Cognitive forcing strategies can be developed through a sequence of 4 maneuvers6:

1.Thinking about your thinking (using metacognition, as described previously).

2.Learning about common cognitive errors. If one were to choose a single kind of cognitive error to learn about, premature diagnostic closure may offer the greatest clinical return on one's investment. Also known as “anchoring,” premature diagnostic closure describes the practice of locking onto an early working diagnosis, subsequently ignoring or failing to seek further data that might refute one's initial impression. The prevalence of this error has been reported to be as high as 90%.9

3.Identification of specific clinical contexts in which diagnostic errors are most likely to occur, commonly known as “pitfalls” (eg, abdominal pain in the elderly).

4.Routine insertion of a cognitive forcing strategy (drawn from maneuver No. 2) into a clinical context known to be error prone (drawn from maneuver No. 3) (eg, consciously refusing to anchor onto a diagnosis of gastroenteritis in an elderly patient presenting with vomiting, diarrhea, and mild abdominal discomfort).

Many seasoned clinicians, through trial and error, have developed cognitive forcing strategies as part of the everyday exercise of apparently intuitive clinical judgment. On hearing the term metacognition, they may feel much like Moliere's bourgeois gentleman, who was stunned and delighted to discover that, for some 40 years, he had been speaking prose. For younger physicians, however, and for clinician-educators who teach residents at the bedside, providing a formal structure for thinking about how we think may be a very useful strategy for learning and teaching about the reduction of medical error in emergency practice.

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References 

  1. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To Err Is Human: Building a Safer Health Care System. Washington, DC: National Academy Press; 1999; Report of the Institute of Medicine
  2. Thomas EJ, Studdert DM, Burstein HR, et al.  Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271
  3. Kuhn GJ. Diagnostic errors. Acad Emerg Med. 2002;9:740–750
  4. Handler JA, Gillam M, Sanders AB, et al.  Defining, identifying, and measuring error in emergency medicine. Acad Emerg Med. 2000;7:1183–1188
  5. Glick TH, Workman TP, Gaufberg SV. Suspected conversion disorder: Foreseeable risks and avoidable errors. Acad Emerg Med. 2000;7:1272–1277
  6. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003;41:110–120
  7. Croskerry P. The cognitive imperative: Thinking about how we think. Acad Emerg Med. 2000;7:1223–1231
  8. Epstein RM. Mindful practice. JAMA. 1999;282:833–839
  9. Voytovich A, Rippey R, Suffredini A. Premature conclusions in diagnostic reasoning. J Med Educ. 1985;60:302–307

☆ Reprints not available from the author.

PII: S0196-0644(02)84943-5

doi:10.1067/mem.2003.20

Refers to article:

  • Cognitive forcing strategies in clinical decisionmaking

    Pat Croskerry
    Annals of Emergency Medicine January 2003 (Vol. 41, Issue 1, Pages 110-120)

Annals of Emergency Medicine
Volume 41, Issue 1 , Pages 121-122, January 2003

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