Diagnostic heuristics: metacognition and other fixes

Summary

The shortcuts in thinking that humans use to solve problems ('heuristics', covered in an earlier review) are not always perfect, and in medicine this can lead to errors in diagnosis. So, how to recognize what is happening and try to combat it? In this review (part 2 of 2) the authors from the USA suggest ways of getting doctors 'to think about the way they think' (an approach known as metacognition) during the process of diagnosis. A number of strategies are considered: for instance, learning to pay more attention to – and acting more readily on – gut feelings of uncertainty, and being more aware of when to take time out to look at possibly uncertain diagnoses from different angles ('What else could it be?' 'Why does this not fit?' 'Let's discuss it with a colleague.'). Even being more consciously aware of when the work environment is too demanding or distracting (the phone never stops ringing, emails are constantly coming in, fatigue is kicking in, etc.) is an important skill. Reflecting on personal errors in diagnosis is another simple, practical example, as is asking for feedback from patients about what worked and what didn't. High risk professions have used checklists for a long time: does medicine need to catch up? Finally, the authors comment that experience can be a two‐edged sword: although experienced doctors generally use heuristics more effectively in diagnosis than inexperienced ones (see part 1), this can be undermined if they also 'become less likely to seek outside opinions or use reference materials'.

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