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Kunitomo K, Gupta A, Harada T, Watari T. The Big Three diagnostic errors through reflections of Japanese internists. Diagnosis (Berl) 2024; 0:dx-2023-0131. [PMID: 38501928 DOI: 10.1515/dx-2023-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 02/27/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To analyze the Big Three diagnostic errors (malignant neoplasms, cardiovascular diseases, and infectious diseases) through internists' self-reflection on their most memorable diagnostic errors. METHODS This secondary analysis study, based on a web-based cross-sectional survey, recruited participants from January 21 to 31, 2019. The participants were asked to recall the most memorable diagnostic error cases in which they were primarily involved. We gathered data on internists' demographics, time to error recognition, and error location. Factors causing diagnostic errors included environmental conditions, information processing, and cognitive bias. Participants scored the significance of each contributing factor on a Likert scale (0, unimportant; 10, extremely important). RESULTS The Big Three comprised 54.1 % (n=372) of the 687 cases reviewed. The median physician age was 51.5 years (interquartile range, 42-58 years); 65.6 % of physicians worked in hospital settings. Delayed diagnoses were the most common among malignancies (n=64, 46 %). Diagnostic errors related to malignancy were frequent in general outpatient settings on weekdays and in the mornings and were not identified for several months following the event. Environmental factors often contributed to cardiovascular disease-related errors, which were typically identified within days in emergency departments, during night shifts, and on holidays. Information gathering and interpretation significantly impacted infectious disease diagnoses. CONCLUSIONS The Big Three accounted for the majority of cases recalled by Japanese internists. The most relevant contributing factors were different for each of the three categories. Addressing these errors may require a unique approach based on the disease associations.
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Affiliation(s)
- Kotaro Kunitomo
- Department of General Medicine, 37028 NHO Kumamoto Medical Center , Kumamoto, Japan
| | - Ashwin Gupta
- Medicine Service, 20034 Veterans Affairs Ann Arbor Healthcare System , Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Taku Harada
- Department of General Medicine, 83943 Nerima Hikarigaoka Hospital , Nerima-ku, Tokyo, Japan
| | - Takashi Watari
- Medicine Service, 20034 Veterans Affairs Ann Arbor Healthcare System , Ann Arbor, MI, USA
- Department of Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of General Medicine, 83943 Nerima Hikarigaoka Hospital , Nerima-ku, Tokyo, Japan
- General Medicine Center, Shimane University Hospital, Izumo shi, Shimane, Japan
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Flemming DJ, White C, Fox E, Fanburg-Smith J, Cochran E. Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. Skeletal Radiol 2023; 52:493-503. [PMID: 36048252 DOI: 10.1007/s00256-022-04166-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/04/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023]
Abstract
The objective of this paper is to explore sources of diagnostic error in musculoskeletal oncology and potential strategies for mitigating them using case examples. As musculoskeletal tumors are often obvious, the diagnostic errors in musculoskeletal oncology are frequently cognitive. In our experience, the most encountered cognitive biases in musculoskeletal oncologic imaging are as follows: (1) anchoring bias, (2) premature closure, (3) hindsight bias, (4) availability bias, and (5) alliterative bias. Anchoring bias results from failing to adjust an early impression despite receiving additional contrary information. Premature closure is the cognitive equivalent of "satisfaction of search." Hindsight bias occurs when we retrospectively overestimate the likelihood of correctly interpreting the examination prospectively. In availability bias, the radiologist judges the probability of a diagnosis based on which diagnosis is most easily recalled. Finally, alliterative bias occurs when a prior radiologist's impression overly influences the diagnostic thinking of another radiologist on a subsequent exam. In addition to cognitive biases, it is also important for radiologists to acknowledge their feelings when making a diagnosis to recognize positive and negative impact of affect on decision making. While errors decrease with radiologist experience, the lack of application of medical knowledge is often the primary source of error rather than a deficiency of knowledge, emphasizing the need to foster clinical reasoning skills and assist cognition. Possible solutions for reducing error exist at both the individual and the system level and include (1) improvement in knowledge and experience, (2) improvement in clinical reasoning and decision-making skills, and (3) improvement in assisting cognition.
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Affiliation(s)
- Donald J Flemming
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, 500 University Drive H066, Hershey, PA, 17033, USA.
| | - Carissa White
- Department of Radiology, Penn State Health Milton S. Hershey Medical Center, 500 University Drive H066, Hershey, PA, 17033, USA
| | - Edward Fox
- Department of Orthopaedics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Julie Fanburg-Smith
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eric Cochran
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Croskerry P, Campbell SG, Petrie DA. The challenge of cognitive science for medical diagnosis. Cogn Res Princ Implic 2023; 8:13. [PMID: 36759370 PMCID: PMC9911579 DOI: 10.1186/s41235-022-00460-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/23/2022] [Indexed: 02/11/2023] Open
Abstract
The historical tendency to view medicine as both an art and a science may have contributed to a disinclination among clinicians towards cognitive science. In particular, this has had an impact on the approach towards the diagnostic process which is a barometer of clinical decision-making behaviour and is increasingly seen as a yardstick of clinician calibration and performance. The process itself is more complicated and complex than was previously imagined, with multiple variables that are difficult to predict, are interactive, and show nonlinearity. They appear to characterise a complex adaptive system. Many aspects of the diagnostic process, including the psychophysics of signal detection and discrimination, ergonomics, probability theory, decision analysis, factor analysis, causal analysis and more recent developments in judgement and decision-making (JDM), especially including the domain of heuristics and cognitive and affective biases, appear fundamental to a good understanding of it. A preliminary analysis of factors such as manifestness of illness and others that may impede clinicians' awareness and understanding of these issues is proposed here. It seems essential that medical trainees be explicitly and systematically exposed to specific areas of cognitive science during the undergraduate curriculum, and learn to incorporate them into clinical reasoning and decision-making. Importantly, this understanding is needed for the development of cognitive bias mitigation and improved calibration of JDM in clinical practice.
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Affiliation(s)
- Pat Croskerry
- Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada.
| | - Samuel G. Campbell
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - David A. Petrie
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Gamborg ML, Mehlsen M, Paltved C, Vetter SS, Musaeus P. Clinical decision-making and adaptive expertise in residency: a think-aloud study. BMC MEDICAL EDUCATION 2023; 23:22. [PMID: 36635669 PMCID: PMC9835279 DOI: 10.1186/s12909-022-03990-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/27/2022] [Indexed: 06/17/2023]
Abstract
Clinical decision-making (CDM) is the ability to make clinical choices based on the knowledge and information available to the physician. It often refers to individual cognitive processes that becomes more dependent with the acquisition of experience and knowledge. Previous research has used dual-process theory to explain the cognitive processes involved in how physicians acquire experiences that help them develop CDM. However, less is known about how CDM is shaped by the physicians' situated cognition in the clinical environment. This is especially challenging for novice physicians, as they need to be adaptive to compensate for the lack of experience. The adaptive expert framework has been used to explain how novice physicians learn, but it has not yet been explored, how adaptive expertise is linked to clinical decision-making amongst novice physicians.This study aimed to analyse how residents utilize and develop adaptive expert cognition in a natural setting. By describing cognitive processes through verbalization of thought processes, we sought to explore their CDM strategies considering the adaptive expert framework.We used concurrent and retrospective think-aloud interviews in a natural setting of an emergency department (ED) at a university hospital, to query residents about their reasoning during a patient encounter. We analysed data using protocol analysis to map cognitive strategies from these verbalizations. Subsequently in a narrative analysis, we compared these strategies with the literature on adaptive expertise.Fourteen interviews were audio recorded over the course for 17 h of observation. We coded 78 informational concepts and 46 cognitive processes. The narrative analysis demonstrated how epistemic distance was prevalent in the initial CDM process and self-regulating processes occurred during hypothesis testing. However, residents who too quickly moved on to hypothesis testing tended to have to redirect their hypothesis more often, and thus be more laborious in their CDM. Uncertainty affected physicians' CDM when they did not reconcile their professional role with being allowed to be uncertain. This allowance is an important feature of orientation to new knowledge as it facilitates the evaluation of what the physician does not know.For the resident to learn to act as an adaptive decision-maker, she relied on contextual support. The professional role was crucial in decisional competency. This supports current literature, which argues that role clarification helps decisional competency. This study adds that promoting professional development by tolerating uncertainty may improve adaptive decisional competency.
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Affiliation(s)
- Maria Louise Gamborg
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark.
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark.
| | - Mimi Mehlsen
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Charlotte Paltved
- Coporate HR MidtSim & Department of Clinical Medicine, Faculty of Health, Aarhus University, Central Denmark Region, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark
| | - Sigrid Strunge Vetter
- Department of Psychology, Faculty of Business and Social Sciences, Aarhus University, Bartholins Allé 11, 8000, Aarhus C, Denmark
| | - Peter Musaeus
- Centre for Educational Development, Aarhus University, Aarhus C, Denmark
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Yager J, Gaudiani JL, Treem J. Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward. J Eat Disord 2022; 10:135. [PMID: 36068601 PMCID: PMC9450436 DOI: 10.1186/s40337-022-00659-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Premature deaths are estimated to occur in 5-20% of patients with anorexia nervosa (AN). Among them, some patients with severe and enduring anorexia nervosa (SE-AN) will die due to the medical complications of malnutrition or to suicide. Almost no literature provides guidance to patients, clinicians, and loved ones regarding clinical characteristics of those with SE-AN who recognize and accept the fact that they will not be able to survive their disease. Consistent with general medical literature on terminal illness and based on the authors' work with patients at this phase of life, we previously described four clinical characteristics of the small group of SE-AN patients who may be considered to have a terminal eating disorder. Following publication of this article, several opinions objecting to these formulations were published. The goals of this article are to respond to the key themes of concern posed by these objections, to extend our discussion of the palliative care and associated needs of these patients and their families, and to suggest ways in which the eating disorder and palliative care fields might develop more definitive criteria and consensus guidelines for the assessment and management of these patients. METHODS Based on a selective narrative review of the literature, our combined experiences with these patients, and clinical reasoning, we address critiques grouped around five major themes: that (1) labels such as terminal AN are dangerous; (2) since AN is a treatable disorder, no SE-AN patients should be considered terminal; (3) a terminal psychiatric condition cannot be defined; (4) the proposed definition is not specific enough; and (5) considerations regarding mental capacity in the proposed criteria do not sufficiently account for the psycho-cognitive impairments in AN. RESULTS Our analysis responds to the critiques of our original proposed clinical characteristics of those with terminal AN. While refuting many of these critiques, we also appreciate the opportunity to refine our discussion of this complex topic and identify that there are multiple stages of SE-AN that can result in good clinical outcomes. Only when all of these have failed to provide adequate amelioration of suffering do a low number of patients progress to terminal AN. CONCLUSIONS By further refining our discussion of terminal AN, we aim to encourage eating disorders and palliative care specialists to develop expert consensus definitions for terminal AN and to generate authoritative clinical guidance for management of this population. By validating terminal AN as a distinct condition, patients with this subcategory of SE-AN, their families, and their caregivers facing end-of-life concerns may be better able to access palliative and hospice care and related services to help improve their overall experiences at this phase of life.
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Affiliation(s)
- Joel Yager
- Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Jonathan Treem
- Department of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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