Factors associated with clinical reasoning ability

Pat Croskerry croskerry at EASTLINK.CA
Sat Sep 10 13:03:17 UTC 2016

Stephanie: I think it all overlaps. The diagnostic process can be very straightforward and seamless at times, but, at others, (often during cognitive overload, fatigue, sleep deprivation) can be excruciatingly complex.

Many of us are out of our depth when it comes to recognising the myriad cognitive factors that can impact decision making. Often, it is the case that decision makers have knowledge deficits about how cognitive and affective biases work. Ironically, the phenomenon is known as ‘bias blind spot’ (a bias against accepting and understanding biases) and it is fairly widespread because many medical curricula do not teach about bias. Although understanding cognition should be a vital objective in medical training, it usually isn’t. Many other domains of human activity are now coming to terms with the impact of bias on decision making (US Intelligence agency, World Bank, NASA, Business, Legal system) – medicine should not get left behind.

Understanding the cognitive processes that underlie diagnostic decision making is high hanging fruit and the preference will always be for more accessible solutions.

Embracing the findings of cognitive science is the first step towards getting at the high hanging fruit in understanding clinical decision making. (Table 1 in the attached paper summarises a number of factors that have been responsible for our failure to understand the diagnostic process).

The paper by Colbert et al is a good example of the direction we should be taking on this.


Pat Croskerry MD, PhD, FRCP(Edin)

Professor, Department of Emergency Medicine,

Director, Critical Thinking Program,

Dalhousie University Medical School,

Halifax, Nova Scotia




and.: Stefanie Lee [mailto:stefanieylee at GMAIL.COM] 
Sent: September 10, 2016 12:51 AM
Subject: Re: [IMPROVEDX] Factors associated with clinical reasoning ability


Thank you all for the thought-provoking insights! To add an observation from the settings where I've worked: a common characteristic of clinicians who rarely get into serious trouble with diagnostic error seems to be their ability to "know what they don't know." 


In practice, this means they are skilled at discriminating when they can confidently make a diagnosis, versus when a case may be out of their depth. 


In the latter instance, they acknowledge and take steps to manage that uncertainty: doing more research on the topic, consulting colleagues, or recommending a course of action that ensures the patient is reevaluated in a timely manner.


If someone does not recognize a case as needing extra attention/assistance, they may offer a diagnosis with more confidence than is warranted, not seek input from others, or fail to convey the need for close followup and/or further workup, increasing the risk of diagnostic error.


-- Questions: How successfully can the ability to "know what you don't know" be fostered in trainees or practicing clinicians? (attached an article on teaching metacognitive skills) 


Does work on this essentially overlap, or does it differ in any way from efforts to teach cognitive debiasing or improve situational awareness?


With appreciation for everyone's input,



On 31 August 2016 at 11:30, Grubenhoff, Joe <Joe.Grubenhoff at childrenscolorado.org <mailto:Joe.Grubenhoff at childrenscolorado.org> > wrote:


It would be great to hear from others on the listserv about this.  What observable behaviors characterize clinicians who excel at diagnosis?

1)      In the academic setting, providers who tend to use a Socratic approach to draw out their learners’ reasoning are often very adept at diagnosis.

2)      Providers who tend to share their personal stories of erroneous diagnosis AND impart their deconstruction of what led to the error demonstrate an introspection and willingness to serve the success of all by admitting their own “faults”: this underlies a general commitment to improve one’s own dx acumen.

3)      The generalist who, when getting advice from a consultant, is willing to say: “I did not know X,Y,Z. Can you explain this to me so I can catch in the future?”

4)      Along the lines of #3, being willing to tell a patient, I’m not sure what this is and I’m going to look something up. (humility and quest for new knowledge)

a.       As a med student I was seeing a gentleman with AIDS in a VA gen surg clinic with deep purple skin lesions. The surgeon told me to go read up on skin manifestations of AIDS since I admitted I knew nothing. The man had Kaposi sarcomas. I’m now a peds ER doc so never see these but the lesson stayed with me.   



Joe Grubenhoff, MD, MSCS| Associate Professor of Pediatrics 
Section of Emergency Medicine | University of Colorado

Children's Hospital Colorado 

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From: Mark Graber [mailto:mark.graber at IMPROVEDIAGNOSIS.ORG <mailto:mark.graber at IMPROVEDIAGNOSIS.ORG> ] 
Sent: Wednesday, August 31, 2016 7:38 AM
Subject: Re: [IMPROVEDX] Factors associated with clinical reasoning ability


Thanks for sharing Dr Manesh’ survey, Shantanu.  


If the goal is to assess their clinical reasoning, I’d like to see other questions, like these:

            When confronted with a new diagnostic challenge, I regularly construct (and document) a differential diagnosis

            When I’m not sure of a diagnosis or ’the next step', I get a second opinion from a peer

            When I’ve reached a tentative diagnosis, I consider whether my conclusion might have been influenced by a cognitive bias


If the goal is broader, looking at success in the diagnostic process, there are other key behaviors that are relevant:

            Have I succeeded in making the patient a partner in the diagnostic process?

            Does my patient know when, why, and how to get back to me if the symptoms persist, change or don’t respond to treatment?

            How often do I personally interact with the radiologists or pathologists interpreting diagnostic tests on my patients?

            According to independent surveys, how effectively am I communicating with my patients?

            Do I keep a record of tests and consults ordered and make sure I close the loop on all of these?

            Do I designate a surrogate to review returning test results if I’m going on vacation?


It would be great to hear from others on the listserv about this.  What observable behaviors characterize clinicians who excel at diagnosis?





Mark L Graber MD FACP

Senior Fellow, RTI International

Professor Emeritus, SUNY Stony Brook

President, Society to Improve Diagnosis in Medicine






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