Recognizing Clinical

Reasoning Errors
Heidi Chumley, MD
Associate Professor, Family Medicine
 Session Objectives
• At the end of this session, participants
should be able to:
– Outline the steps of the clinical reasoning
process.
– Define cognitive dispositions to respond
(CDRs) and describe several CDRs seen with
diagnostic reasoning errors.
– Recognize clinical reasoning errors in
common educational settings.
 Clinical Reasoning
• “the cognitive process necessary to evaluate
and manage a medical problem”

Reasoning

Skill Knowledge
 Medical Errors
• 44,000 to 98,000 deaths per year due to
medical errors
• Many systematic and individual factors
contribute to medical errors
• Recent attention on cognitive errors
(clinical reasoning, diagnostic reasoning,
decision-making)
Cognitive Errors

Zhang, JAMIA, 2002

 Cognitive Errors
• Of 301 Malpractice claims, 59% involved
diagnostic errors that led to poor
outcomes – Gandhi, 2006
• Of patients admitted with 10 days of
outpatient visit, 10% due to diagnostic
error – Singh, 2007
• Autopsy series showed 24% missed
diagnosis – Shojania, 2003
 Diagnostic process

Differential Diagnosis
Generation

Information
Diagnosis Refinement
gathering

Diagnosis Verification
 Why are errors made?
• Failure/delay of eliciting information –
Singh, 2007
• Suboptimal weighing of critical pieces of
information from H&P – Singh, 2007
• Overreliance on diagnostic testing –
Bordage, 1999
 Cognitive Dispositions to
Respond
• Biases that can lead to
diagnostic errors
• Mental shortcuts
running amuck
• Croskerry defines 32,
Acad Med, 2003: 78(8)
 Cognitive Dispositions to
Respond
• Information-gathering • Probability
– Unpacking – Aggregate bias
– Availability – Base-rate neglect
– Anchoring – Gender bias
– Premature closure – Gambler’s fallacy
• System – Posterior probability
– Diagnosis momentum error
– Feedback sanction
Croskerry, 2003
– Triage cueing
 Information-gathering problems
• Unpacking – failure to elicit all
relevant information
• Availability – recent exposure
influences diagnosis
• Anchoring – holding onto a
diagnosis after receiving
contradictory information
• Premature closure – accepting a
diagnosis before it is fully verified

Present at all levels, start watching for these in students

 Clues to Information-Gathering
Problems
• Limited differential diagnosis (unpacking,
availability)
• Lack of attention to contradictory
information (anchoring)
• Lack of pertinent negatives (premature
closure)
 Diagnostic Errors
Unpacking
Availability
Differential Diagnosis
Generation
Anchoring

Information
Diagnosis Refinement
gathering Premature
closure

Diagnosis Verification
 Systems contributions
• Diagnosis momentum – early
diagnosis by another provider
is accepted as definite
• Feedback sanction – final
diagnosis does not return to
initial decision-maker
• Triage cueing – location cues
management (seen through
the lens of the first provider)

Present at all levels, more likely to see in residents

 Clues to System Contributors
• Lack of primary symptom data (diagnostic
momentum)
• Inattention to closing the loop (feedback
sanction)
• Non diagnoses: non-cardiac chest pain;
no gynecologic cause for lower abdominal
pain (triage cueing)
 Probability Pitfalls
• Aggregate bias – aggregate
data do not apply to my patients
• Base-rate neglect – ignoring the
true prevalence
• Gender bias – gender
inappropriately colors probability
• Gambler’s fallacy – sequence of
same diagnoses will not
continue
• Posterior probability – sequence
of same diagnoses will continue
Best seen during continuity experiences, residency
 Clues to Probability Pitfalls
• Didn’t meet criteria, but I…(aggregate)
• Rare diagnoses high on list, increased
testing (base-rate neglect)
• Comments about probability (Gambler’s
fallacy, posterior probability)
 Two Others
• Representative restraint – ruled out
because the presentation is not typical
• Search satisfying – search is called off
when something is found
 Summing Up
• Reasoning errors are common
• Identifying/naming the CDRs is an
important part of reflection
• No gold standard for assessing reasoning
in our learners – nothing to replace our
conversations and helping them think
about how they are thinking
• Are cognitive errors treatable? Yes
Questions?