There are many procedures that we carry out in our clinical work that are considered ‘risky’ and often, in an attempt to reduce that risk, checklists are created to ensure that they are carried out in an appropriate, consistent and approved manner. In contrast, the process of making a diagnosis (which by best estimates has a failure rate in Emergency Medicine of 10-20%) is mostly left up to individuals to carry out in whatever manner they have developed and often with limited oversight of that process. The frailties of our cognition are long established and whilst it may not be possible, or even desirable, to have all clinicians thinking alike, we must acknowledge these faults inherent in human thinking and make deliberate efforts to mitigate them.
One strategy that may help with this problem is metacognition, encouraging clinicians to think about their thought processes. What follows are six simple questions that attempt to trigger a more reflective process by diagnosticians and potentially reduce the impact of erroneous thinking.
They are: Who? What? Where? Why? When? and How?
Who? Who is my patient really?
As we deal with a patient all sorts of shortcuts occur in our thinking to make it easier for us to process the excess of information we are receiving. Part of this process causes us to ’round off the edges’ of an individual patient so we can categorise them in to a familiar pattern. This leads to us stereotyping people by person (drug user, regular) or disease (asthmatic, Crohn’s), failing to see their individual problems and potentially missing clues that may point to alternative diagnoses. Patients can also be frustrating, particularly if they behave badly, appear to have brought harm upon themselves or because we don’t know what is going on. These feelings interfere with our ability to process information clearly and goes someway to explaining why psychiatric patients are at high risk for misdiagnosis of physical disease.
We need to take a breath and consider who we are REALLY dealing with, rather than treating the composite patient we have created in our head.
What? What information am I actually using?
In Emergency Medicine in particular but actually across all specialties, we are often missing information that would be helpful to us when making a diagnosis. This means that as we try and construct a coherent picture of what is going on there are inevitable gaps in our knowledge. Unhelpfully, our brain (in a misguided attempt to make things easier) automatically tries to fill these gaps with assumptions based on previous experiences. In a complementary twist, our brain also notices inconvenient inconsistencies that would throw our preferred story off kilter and chooses to subtly alter or ignore these to reduce cognitive stress. The end result of these two processes is that we are not diagnosing with the information we have but with the information that suits us!
We should stop and consider the totality of the information available, looking particularly for features that do not fit our current thinking.
Where? Where is my information coming from?
All information is not equally valid but this should be decided upon with reasoned consideration… unfortunately our brain chooses to make snap judgments. Information that comes to us from early in our contact with a case (triage notes, ambulance handovers, telephone calls for help) carries more weight than data that arrives later (blood results, relative’s phone call, nurse feedback) regardless of its actual accuracy. Similar judgments are made with information from ‘official’ sources (GP letters, care home records) or information handed over to us as secondhand summaries from fellow health professionals despite the fact it may already have passed through a number of unhelpful cognitive filters.
Information must be assessed for reliability but we must give all information a chance to be considered reliable and not just dismiss it based on snap judgments.
Why? Why might I be wrong?
Above all else our brains are programmed to believe what we already think is true. Once we have a thought in our heads about a diagnosis the processes described above are slowly fine tuned to make that thought a reality… to us anyway! Whilst experience is an incredibly powerful tool for us as diagnosticians, it is also a gaping hole in our armour and so we must be extremely careful when we see ‘another’ pulmonary embolus/ appendix/ irritable hip/drunk. Jumping to a conclusion too soon stops us taking the time to consider rarer diagnoses, multiple problems and atypical presentations.
Our brains are inherently biased towards accepting what we already believe and so we must actively consider why we might be wrong if we are ever to spot the errors in our diagnostic construction.
When? When will I review my diagnosis?
If we accept that we will make errors in our diagnostic process, we must plan to review our decisions after a suitable period of time: this is particularly true if we are waiting for more information to arrive (test results) or clarification of existing data (relative phoning with drug names). Watching carefully for new data that contradicts our current hypothesis is vital as our thinking will try to explain it away as an anomaly or perhaps even ignore it. At that review we must also reconsider all the previously gathered material as the new data may alter the relevance or reliability of that original information. Be careful when considering the condition of the patient or their response to our treatment as a marker of being correct. Many patients will get better regardless of what we do or with fairly non-specific interventions!
Mistakes happen, that’s inevitable, but planning to catch those mistakes and actively looking for where we may have erred is a choice.
How? How do I feel now?
Our job is to make diagnoses and with training and experience comes confidence, and rightly so. We cannot spend our careers second guessing ourselves at every turn, so if we have reflected appropriately on a case and have a review process in place it is time to move on. However, most of us have experienced that nagging doubt in the back of our minds that says something isn’t quite right, a concern that we just can’t shake but we feel unwilling to voice. It is absolutely vital that we listen to these ‘gut instincts’ and don’t ignore them. Taking a diagnosis to someone else and explaining it can sometimes lay bare our errors (it is always easier to see someone else’s biases), as can unexpected results from tests we have arranged or an additional piece of history from a relative but we must welcome this process rather than fear it. It may mean the undoing of hours of work and the embarrassment of an explanation to a patient or their family but it gives us an incredible opportunity to learn and most importantly keeps the patient safe.
Confidence is good but regardless of the consequences for us, we must welcome the nagging doubts in our head, the questioning of colleagues and incompatible data as opportunities, not threats.
Six questions to make us stop and consider our diagnostic thought processes: surely it is worth the mental effort to try and improve a procedure with nearly a 1:5 error rate.
You’d want your doctor to take that time, wouldn’t you?