The Cognitive Dimension

In his recently published New Yorker (January 29, 2007) article, “What’s the Trouble?”, Dr. Jerome Groopman explores the issue of how doctors think.

Groopman quotes Dr. Pat Croskerry, a emergency medicine physician at Dartmouth General Hospital, Halifax, Nova Scotia, stating that, as a medical student, Croskerry was surprised at “how little attention was paid to the ‘cognitive dimension’ of clinical decision-making—the process by which doctors interpret their patients’ symptoms and weigh test results in order to arrive at a diagnosis and a plan of treatment.”

Croskerry opines that many medical misdiagnoses result from identifiable—and often preventable—errors in thinking.

In making diagnoses, most doctors rely on “shortcuts or rules of thumb,” known as “heuristics.”

Although heuristic principles help doctors diagnose patients, they can sometimes lead to serious errors.

One type of mistake physicians often make is called a “representativeness” error. According to Groopman, this happens when doctors base their judgments on what is “typically true,”—failing to consider other diagnostic possibilities—and attribute symptoms to the wrong cause.

Doctors also make mistakes when they allow their judgments about a patient’s condition to be influenced by the symptoms of other patients they have just seen, as is often the case during disease epidemics.

Another type of error, dubbed “availability,” refers to the tendency to consider a patient’s symptom complex to be relevant as similar examples—“templates of disease”— come to mind.

Sometimes a doctor’s impulse to protect a patient he admires can adversely affect his judgment. Croskerry terms this tendency an “affective” error.

When physicians are confronted with diagnostic uncertainty, they are susceptible to underlying emotions and personal biases that can cloud their ability to make sound decisions.

Croskerry believes that the first step toward developing an awareness of these issues in medical practice is to recognize that “how doctors think can affect their success as much as how much they know, or how much experience they have.”

As clinicians, it behooves us to approach the patient with an attitude of humility and respect. Both Groopman and Croskerry should remember that, at core, the diagnostician’s ego plays a large role in errors of medical judgment as well.


One comment on “The Cognitive Dimension

  1. […] Morbidity and mortality secondary to medical error is staggering.  Groopman has delineated some of the foibles in medical decision making.  Gawande has proposed a standard check list to curb the number of surgical errors.  Leading […]

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