Is Misdiagnosis Inevitable?

Leigh Page

Disclosures

March 28, 2016

In This Article

Diagnostic Shortcuts Can Get in the Way

Dr Graber says one common way that doctors make misdiagnoses is by not undertaking a step-by-step differential diagnosis. Instead, doctors often apply heuristics, which are mental shortcuts based on experience. Dr Graber says doctors use heuristics a lot, and he doesn't expect them to stop—they are very efficient and are accurate in many situations—but he does think heuristics should be used more sparingly.[14]

Going with your gut and not overthinking a problem was popularized by Blink, the 2007 bestseller by Malcolm Gladwell. However, Dr Graber and other researchers say that instincts don't help when the diagnostic problem doesn't match past experience, such as when symptoms present atypically. They say doctors need to know when to stop thinking heuristically and switch to the slower process of thinking analytically.

Most doctors already see the need for combining heuristics with an analytical approach. The QuantiaMD survey asked clinicians to state their preferences between medical as an "art," which involves heuristics, and medicine as a "science," which involves an analytical approach. Whereas 14% said medicine is a science and 12% said it's an art, fully 74% said that it's both.

Gurpreet Dhaliwal, MD, a professor of clinical medicine at UCSF, has been a proponent of examining and improving one's own cognitive processes in making diagnoses, called "metacognition." For example, he reviews case reports in medical journals to get an idea of how the diagnostic process needs to be adjusted. "Once you know your brain is capable of making errors, you're going to be more careful about the diagnoses you make," he says.

Dr Wachter, who teaches residents at UCSF, says younger physicians are taking metacognition more seriously. When reviewing cases at morbidity and mortality conferences, "I hear my residents refer to things like an 'anchoring error' [when the doctor clings to an initial impression, despite contradictory information coming later]," he says. "You didn't hear that term 10 years ago."

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