Laura M. Cascella, MA
A look at MedPro claims data for otolaryngology (ENT) shows that allegations related to diagnosis are not as prevalent as allegations involving surgical treatment. However, claims involving diagnosis-related allegations can be significant in terms of poor patient outcomes. These claims often involve cancer, and most of the allegations are related to a failure to order or delay in ordering diagnostic testing, which is compounded by:
- A narrow diagnostic focus, especially when faced with an atypical presentation or symptoms matching a chronic, previously known condition
- Misinterpretation of diagnostic studies
- Failure to pursue an abnormal finding1
A common risk factor in diagnosis-related claims for all specialties — including otolaryngology — is clinical judgment, which includes clinical reasoning and decision-making. Because clinical judgment is a complex process that involves various cognitive functions, it's easy to understand why it is a driving force in diagnosis-related claims.
Much of the literature focusing on diagnostic errors and clinical reasoning recognizes the dual decision-making model as the basis for clinicians' diagnostic process. The dual decision-making model consists of two types of clinical reasoning: Type 1 and Type 2. In Type 1, the reasoning process is automatic, intuitive, reflexive, and nonanalytic. The practitioner arranges patient data into a pattern and arrives at a working diagnosis based on previous experience and/or knowledge. In Type 2, the reasoning process is analytic, slow, reflective, and deliberate. This type of thinking often is associated with cases that are complex or with which the clinician is unfamiliar.2
Type 1 and Type 2 are not mutually exclusive, and practitioners tend to use both depending on the circumstance. However, research suggests that most clinical work involves Type 1 reasoning.3 Although the automatic, intuitive processes that occur in Type 1 are a requisite part of the thought process and often very effective, they also are vulnerable to cognitive errors.
Research about the cognitive aspect of diagnostic errors suggests that errors in clinical reasoning often arise from several sources, including faulty heuristics, cognitive biases, and affective influences.4
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. Some common biases included anchoring, availability, and overconfidence.
The term "affective influences" refers to emotions and feelings that can sway clinical reasoning and decision-making.5 For example, preconceived notions and stereotypes about a patient might influence how the practitioner views the patient's complaints and symptoms.
Although cognitive processes are well-studied, further research is needed to determine how best to prevent the flaws in clinical judgment that can lead to diagnostic errors. A number of strategies and solutions have been proposed, which range from the use of diagnostic aids, to process changes, to debiasing techniques.
For example, some researchers suggest that the use of evidence-based decision support systems, clinical guidelines, checklists, and clinical pathways can help support the clinical reasoning and decision-making processes. However, they note that although these tools can be useful, "unless they are well integrated in the workflow, they tend to be underused."6 Additionally, incorporating a diagnostic review process into the workflow pattern might be helpful. The review may include timeouts to consider and reflect on working diagnoses, as well as the solicitation of second opinions.
Consideration of how various diagnostic strategies can be implemented in everyday clinical activities may help ENT providers begin to take steps toward managing diagnostic risks.
The Society to Improve Diagnosis in Medicine (SIDM) offers a clinical reasoning toolkit for trainees, clinicians, and teachers. The toolkit supports awareness and better understanding of diagnostic reasoning, cognitive psychology, and diagnostic errors. Resources within the toolkit include links to books and articles, slide presentations, and videos focusing on clinical reasoning and cognitive errors.
2 Nendaz, M., & Perrier, A. (2012, October). Diagnostic errors and flaws in clinical reasoning: Mechanisms and prevention in practice. Swiss Medical Weekly, 142:w13706; Ely, J. W., Graber, M. L., & Crosskerry, P. (2011, March). Checklists to reduce diagnostic errors. Academic Medicine, 86(3), 307–313.
3 Nendaz, et al., Diagnostic errors and flaws in clinical reasoning; Crosskerry, P., Singhal, G., & Mamede, S. (2013, October). Cognitive debiasing 1: Origins of bias and theory of debiasing. BMJ Quality & Safety, 22(Suppl 2), ii58–ii64.
4 Phua, D. H., & Tan, N. C. (2013). Cognitive aspect of diagnostic errors. Annals of the Academy of Medicine, Singapore, 42(1), 33–41.
5 Crosskerry, P., Abbass, A. A., & Wu, A. W. (2008, October). How doctors feel: Affective influences in patient's safety. Lancet, 372, 1205–1206; Phua, et al. Cognitive aspect of diagnostic errors.
6 Ely, et al., Checklists to reduce diagnostic errors.