Advancing diagnostic excellence: the cognitive challenge for medicine

Croskerry, Pat; Clancy, Mike

doi:10.1136/bmj.o799

Cited by 3 publications

(1 citation statement)

References 12 publications

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“…Some clinicians might publicly voice denial that terminal AN exists while privately acknowledging that terminality exists for some patients. Some may be influenced by a host of cognitive and affective biases and/or concerns regarding social or professional approbation [25][26][27], which might lead some clinicians to forms of denial, in which they essentially avoid facing the realities of these terminal states. In any case, those who persist in denying even the possibility that the condition of terminal AN exists do these patients and their families a great disservice.…”

Section: Discussionmentioning

confidence: 99%

Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward

Yager

Gaudiani²,

Treem

2022

J Eat Disord

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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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Section: Discussionmentioning

confidence: 99%

Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward

Yager

Gaudiani²,

Treem

2022

J Eat Disord

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The Quest for Diagnostic Excellence in the Emergency Department

Pulia,

Papanagnou,

Croskerry

2024

The Joint Commission Journal on Quality and Patient Safety

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FRAMED: a framework facilitating insight problem solving

Isoda,

Shimizu,

Suzuki

2024

Diagnosis

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Insight has been studied as an element of problem solving in the field of cognitive psychology and may play an important role in clinical reasoning. We propose a new strategy based on theories that promote insight that may help generate further diagnostic hypotheses by reviewing the interpretation of a case and an individual’s list of differential diagnoses from multiple perspectives: formation (F), re-encoding (R), analogy (A), modification (M), elaboration (E), and deliberation (D) (FRAMED). The FRAMED strategy may help clinicians overcome misinterpretations and cognitive bias by systematically reflecting on previous clinical reasoning processes from multiple perspectives.

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Advancing diagnostic excellence: the cognitive challenge for medicine

Cited by 3 publications

References 12 publications

Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward

Eating disorders and palliative care specialists require definitional consensus and clinical guidance regarding terminal anorexia nervosa: addressing concerns and moving forward

The Quest for Diagnostic Excellence in the Emergency Department

FRAMED: a framework facilitating insight problem solving

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