Clinical Judgment: What Is It, and How Does It Contribute to Diagnostic Errors?
Laura M. Cascella, MA
Errors in diagnosis are a serious concern in healthcare from a patient safety perspective as well as a medical liability standpoint. MedPro closed claims data show that allegations related to diagnostic errors are prevalent across specialties and healthcare locations. Closed claims data also show that clinical judgment is a major risk factor in diagnosis-related allegations.
Clinical judgment refers to the thought process (clinical reasoning) that allows healthcare providers to arrive at a conclusion (clinical decision-making) based on objective and subjective information about a patient. An article in the Journal of Evaluation in Clinical Practice explains that “Clinical judgment is developed through practice, experience, knowledge and continuous critical analysis. It extends into all medical areas: diagnosis, therapy, communication and decision making."1
Clinical judgment can involve both automatic, intuitive reasoning and analytic, reflective reasoning. These types of reasoning are not mutually exclusive; healthcare providers might switch their judgment strategy based on the circumstances they encounter. Further, because the cognitive processes involved in clinical judgment are complex, they are prone to various cognitive errors, such as faulty heuristics/cognitive biases and affective influences.2
Faulty Heuristics and Cognitive Biases
The term “heuristics” refers to mental shortcuts in the thought process that help conserve time and effort. These shortcuts are an essential part of thinking, but they are also prone to error. Cognitive biases occur when heuristics lead to faulty decision-making.3 Some common biases include those listed below:
- Anchoring. Anchoring refers to a snap judgment or tendency to diagnose based on the first symptom or lab abnormality.
- Under-adjustment. Under-adjustment is the inability to revise a diagnosis based on additional clinical data.
- Premature closure. Premature closure refers to the termination of the data-gathering process (e.g., patient history, family history, and medication list) before all of the information is known.
- Primacy effect. In primacy effect, the provider has a tendency to show bias toward initial information.
- Confirmation. Confirmation bias occurs if a clinician manipulates subsequent information to fit an initial diagnosis.
- Availability. Availability bias can occur if a clinician considers a diagnosis more likely because it is forefront in his or her mind. Past experience and recent, frequent, or prominent cases can all play a role in availability bias.
- Overconfidence. Overconfidence bias refers to an overestimation of an individual’s own knowledge and skill, as well as an inability to identify knowledge gaps. Overconfidence bias might result from a lack of feedback related to diagnostic accuracy, which may in turn cause clinicians to overestimate their diagnostic precision. As such, researchers suggest that overconfidence might increase as a doctor’s level of expertise increases.4
Affective Influences
Whereas cognitive biases are lapses in thinking, the term “affective influences” refers to emotions and feelings that can sway clinical judgment.5 Preconceived notions and stereotypes about a patient might influence how a healthcare provider views the patient’s complaints and symptoms. For example, if a patient has a history of substance abuse, the provider might view complaints about pain as drug-seeking behavior. Although this impulse might be accurate, the patient could potentially have a legitimate clinical issue.
Additionally, certain factors might trigger negative feelings about a patient that can cause the provider to inadvertently judge or blame the patient for his/her symptoms or condition. For example, a patient’s obesity might be attributed to laziness or general disregard for health and wellness. Likewise, a patient who is noncompliant with follow-up care might be viewed as difficult — in reality, though, the noncompliance might be related to financial issues.
In an article titled “Why Doctors Make Mistakes,” Dr. Jerome Groopman discusses how negative feelings can lead to attribution bias, a type of affective influence. Dr. Groopman notes that this type of bias accounts for many diagnostic errors in elderly patients. For example, clinicians might have a tendency to attribute elderly patients’ symptoms to advancing age or chronic complaining, rather than exploring other potential causes.6
Positive feelings about patients also can affect diagnostic decisions. In outcome bias, for example, a provider might overlook certain clinical data in order to select a diagnosis with better outcomes. By doing so, the clinician is placing more value on what he/she hopes will happen, rather than what might realistically happen.
In addition to positive and negative feelings about patients, provider and patient characteristics — such as age, gender, socioeconomic status, and ethnicity — also can affect the diagnostic process. Consider that research has shown various biases, both explicit and implicit, related to race, ethnicity, gender, and other factors in the management of patients’ pain.7
A variety of other factors also can affectively influence a doctor’s reasoning, such as:
- Environmental circumstances, e.g., high levels of noise or frequent interruptions
- Sleep deprivation, irritability, fatigue, and stress
- Mood disorders, mood variations, and anxiety disorders 8
The complex interaction between these influences and cognitive biases can have a profound effect on clinical reasoning and decision-making, which in turn can lead to various lapses in clinical judgment.
For more information about diagnostic errors and clinical judgment, see the Society to Improve Diagnosis in Medicine’s Clinical Reasoning Toolkit and the Agency for Healthcare Research and Quality’s Improving Diagnostic Safety website.
1 Kienle, G. S., & Kiene, H. (2011, August). Clinical judgment and the medical profession. Journal of Evaluation in Clinical Practice, 17(4), 621-627.
2 Phua, D. H., & Tan, N. C. (2013). Cognitive aspect of diagnostic errors. Annals of the Academy of Medicine, Singapore, 42(1), 33–41.
3 Ibid.
4 Clark, C. (2013, August 27). Physicians’ diagnostic overconfidence may be harming patients. HealthLeaders Media. Retrieved from http://www.healthleadersmedia.com/content/QUA-295686/Physicians-Diagnostic-Overconfidence-May-be-Harming-Patients; Phua, et al., Cognitive aspect of diagnostic errors.
5 Crosskerry, P., Abbass, A. A., & Wu, A. W. (2008, October). How doctors feel: Affective influences in patients' safety. Lancet, 372, 1205–1206; Phua, et al. Cognitive aspect of diagnostic errors.
6 Groopman, J. (2008, September/October). Why doctors make mistakes. AARP Magazine, p. 34.
7 Cascella, L. M. (2017). Lurking beneath the surface: Bias in pain management. MedPro Group. Retrieved from www.medpro.com/documents/10502/2820774/Article_Bias+in+Pain+Management.pdf
8 Crosskerry, P., et al., How doctors feel.
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