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Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error

  • Martin A. Schaller-Paule ORCID logo EMAIL logo , Helmuth Steinmetz , Friederike S. Vollmer , Melissa Plesac , Felix Wicke and Christian Foerch
Published/Copyright: March 24, 2021
Diagnosis
From the journal Diagnosis Volume 8 Issue 4

Abstract

Objectives

Errors in clinical reasoning are a major factor for delayed or flawed diagnoses and put patient safety at risk. The diagnostic process is highly dependent on dynamic team factors, local hospital organization structure and culture, and cognitive factors. In everyday decision-making, physicians engage that challenge partly by relying on heuristics – subconscious mental short-cuts that are based on intuition and experience. Without structural corrective mechanisms, clinical judgement under time pressure creates space for harms resulting from systems and cognitive errors. Based on a case-example, we outline different pitfalls and provide strategies aimed at reducing diagnostic errors in health care.

Case presentation

A 67-year-old male patient was referred to the neurology department by his primary-care physician with the diagnosis of exacerbation of known myasthenia gravis. He reported shortness of breath and generalized weakness, but no other symptoms. Diagnosis of respiratory distress due to a myasthenic crisis was made and immunosuppressive therapy and pyridostigmine were given and plasmapheresis was performed without clinical improvement. Two weeks into the hospital stay, the patient’s dyspnea worsened. A CT scan revealed extensive segmental and subsegmental pulmonary emboli.

Conclusions

Faulty data gathering and flawed data synthesis are major drivers of diagnostic errors. While there is limited evidence for individual debiasing strategies, improving team factors and structural conditions can have substantial impact on the extent of diagnostic errors. Healthcare organizations should provide the structural supports to address errors and promote a constructive culture of patient safety.

Keywords: cognitive bias; continuing education; debiasing; decision making; patient safety; quality
Corresponding author: Martin A. Schaller-Paule, MD, Department of Neurology, University Hospital Frankfurt, Goethe-University, Schleusenweg 2 – 16, D-60528 Frankfurt am Main, Hesse, Germany, Phone: +49 69 6301 6875, Fax: +49 69 6301 4498, E-mail:

Acknowledgments

We would like to thank Lucie Friedauer and Mohammad Alotaibi for their help concerning the case example and highly commend the team of Dr. Pauls and Dr. Kovacs of the Senckenberg Institute for Insect Biology Frankfurt, who eagerly provided insights into beetle biology. Furthermore we want to thank Pat Croskerry for his intellectual guidance and the permission to refer to his work.

  1. Research funding: None declared.

  2. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  3. Competing interests: None declared.

  4. Ethical approval: Not applicable.

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Received: 2019-11-27
Accepted: 2021-02-08
Published Online: 2021-03-24
Published in Print: 2021-11-25

© 2021 Walter de Gruyter GmbH, Berlin/Boston

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  26. Letters to the Editor
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https://doi.org/10.1515/dx-2019-0108
Keywords for this article
cognitive bias; continuing education; debiasing; decision making; patient safety; quality

Articles in the same Issue

  1. Frontmatter
  2. Reviews
  3. An overview of mental health during the COVID-19 pandemic
  4. Potential mechanisms of action of convalescent plasma in COVID-19
  5. Mini Review
  6. Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education
  7. Opinion Papers
  8. Learning clinical reasoning from the fictional detectives
  9. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal
  10. (F)utility of urine Bence Jones proteins for “routine” screening for plasma cell dyscrasia
  11. COVID-19 and the Le Chatelier’s principle
  12. Original Articles
  13. Are sniffer dogs a reliable approach for diagnosing SARS-CoV-2 infection?
  14. Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients
  15. Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool
  16. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology
  17. Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
  18. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study
  19. Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
  20. Postnatal ultrasound follow-up in neonates with prenatal hydronephrosis
  21. Clinical performance of amperometry compared with enzymatic ultra violet method for lactate quantification in cerebrospinal fluid
  22. Case Report – Lessons in Clinical Reasoning
  23. Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error
  24. Case Report
  25. The COVID trap: pediatric diagnostic errors in a pandemic world
  26. Letters to the Editor
  27. Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis
  28. Serious game training in medical education: potential to mitigate cognitive biases of healthcare professionals
  29. Revisiting handoffs: an opportunity to prevent error
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