Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

Abstract

Objectives Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care. Case presentation A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli. Conclusions Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

Diagnostic Delays in Sepsis: Lessons Learned From a Retrospective Study of Canadian Medico-Legal Claims

“…Early screening tools such as quick Sequential Organ Failure Assessment scores (29) have potential to mitigate bias but in order for physicians to apply them, infections need to be in the differential diagnosis. Physicians might also consider cognitive debiasing strategies (30, 31), such as deliberately reflecting (31), using decision support systems (32), and drawing collective intelligence from teams (33) to improve patient assessments.…”

Hidden biases in clinical decision-making: potential solutions, challenges, and perspectives

“…Should we then just accept this bitter truth or try to put all our efforts into challenging biases? Both are neither realistic nor advisable [21].…”

“…Therefore, diagnostic errors, far from being a negligible minor issue, constitute a major burden on patients and families and require policymakers to deploy urgent and concrete solutions. The major factors leading to diagnostic errors are [21]: i. team factors (blind obedience, premature closure); ii. system factors (no interdisciplinarity, streamlined workflow, poor re-evaluation processes); iii.…”

“…The importance of biases among several cognitive factors could never be overestimated as they are considered responsible for about 1 out of 3 of all diagnostic errors [22,24]. Moreover, high levels of expertise, though preserving from several biases, don't make professionals immune to other cognitive errors associated with the overstatement of one own ability and accumulated experience [21,[30][31].…”

“…Besides, activities and intervention projects aimed at raising awareness of the importance of biases and errors are fundamental to creating a collective culture of healthy self-criticism. Team meetings, good practices, dialogue, and peer-review between professionals should all be vigorously encouraged to improve the overall quality of clinical decision-making [21].…”