November 2012: Croskerry on Diagnostic Errors

The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Croskerry P. Acad Med. 2003; 78(8): 775-780. 

If you recognize Pat Croskerry’s name, then chances are you’ve thought a bit about cognitive error in your clinical decision making. If not, a quick glance at some of the published titles from this Scottish emergency medicine physician will help you calibrate his perspective on the subject: Overconfidence in Clinical Decision Making,¹ Emergency Medicine: A Practice Prone to Error?,² and The Affective Imperative: Coming to Terms with our Emotions.³ The cognitive influence on diagnostic error has come to the forefront of medical education thanks in part to Croskerry’s work.

This post highlights one of Croskerry’s articles in which he not only introduces and summarizes specific types of cognitive errors (see his 2-page List in the above link), but he also invites us down a pathway toward improving matters. Croskerry has cited that diagnostic errors account for 10-15% of medical error⁴ and, though most frequent in internal, family, and emergency medicine, he reminds us that cognitive errors can be made by physicians in all specialties and, I would argue, any healthcare professional responsible for a clinical decision about patient care.

To change practice, Croskerry’s charge to educators and practitioners is three-fold. First, we must recognize the impact and extent of cognitive errors in clinical decision-making. Second, we must “refute the inevitability” of these errors. Third, we must get rid of the “pessimism” preventing us from fixing the problem.^{p 776}

This article, like many of Croskerry’s publications, reads as a call to action. He writes that we need to “de-bias” the cognitive patterns of diagnostic thinking prone to error. “It is not unrealistic” he writes of this charge, and the barriers standing in the way “are not insurmountable.”⁷⁷⁶ Croskerry’s published works, with their tables, lists, and appendices collectively signal an alarm for urgency, but it’s his style of writing that may ultimately motivate each of us to respond.

Bottom Line:

If you’re new to Pat Croskerry or the literature on cognitive diagnostic errors, this article is an enthusiastic first step. You’ll reference this article because of the list of “cognitive dispositions to respond,” formerly known as “physician biases” (see page 777); you’ll recommend it to a friend because of the tone in his writing, (see page 779). 

References:

1. Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med. 2008 May;121(5 Suppl):S24-9.

2. Croskerry P, Sinclair D. Emergency medicine: A practice prone to error? CJEM. 2001 Oct;3(4):271-6.

3. Croskerry P. Commentary: The affective imperative: coming to terms with our emotions. Acad Emerg Med. 2007 Feb;14(2):184-6.

4. Schiff G, Hasan O, Kim S et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med 2009; 169: 1881-7. Cited in Croskerry P. Better clinical decision making and reducing diagnostic error. J R Coll Physicians Edinb, 2011; 41: 155-62.