Creativity and diagnostic reasoning

Introduction

Diagnosis is a fundamental physician competency. The diagnostic process involves multiple steps, and hypothesis generation remains central to the entire process. Once the diagnostic hypothesis is generated using a particular diagnostic strategy, a specific perspective is established. However, this perspective is often influenced by heuristics and cognitive biases. Although a specific perspective enables efficient selection and processing of information, it can sometimes lead to erroneous conclusions [1]. Moreover, even when an error is recognized, it can sometimes be difficult to shift away from an established perspective. In situations when cognitive biases strongly influence diagnostic reasoning and increase the risk of diagnostic errors, or when encountering challenging cases that lead to an impasse, it becomes necessary to generate hypotheses from a new perspective. These are precisely the moments when creativity must be exercised. By definition, creativity involves generating novel and useful ideas or solutions, which inherently requires looking at problems from fresh perspectives [2]. We can say that a perspective is novel when it is newly adopted within a thinking process, even if it was previously known [3].

Before discussing how creativity relates to diagnostic reasoning, it is necessary to organize the models of reasoning in diagnosis. Forms of reasoning include deduction, induction and abduction [4]. Induction derives general rules from specific observations (e.g., “All observed swans are white, so all swans must be white”) [4]. Abduction, on the other hand, involves inferring the plausible explanation for given facts (e.g., “The ground is wet; the best explanation is that it rained”) [4]. Diagnostic reasoning is conducted through the hypothetico-deductive method, where multiple hypotheses are generated based on observed patient information [5]. This process of hypothesis formation is abduction [4], [5], [6]. On the other hand, during the subsequent hypothesis testing process, deductive reasoning is involved, such as reasoning that “if a specific test result is positive/negative, the likelihood of a particular disease increases/decreases.” [5], 6] Additionally, in diagnostic reasoning, inductive reasoning may also play a role, as in cases where clinicians rely on past experiences with multiple similar cases that were diagnosed with the same disease [5], 6]. Therefore, diagnostic reasoning is a complex process involving multiple forms of reasoning. In diagnostic reasoning, the dual-process theory (DPT) [7] is well known; however, this theory encompasses not only reasoning but also other cognitive processes such as thinking and decision-making, making it a broad cognitive model [7]. Abduction, on the other hand, is a type of reasoning and is contrasted with deduction and induction. Since hypotheses can be formed intuitively from patient information or through analytical reasoning, abduction can occur through System 1 or System 2 processes [4].

Creativity: a factor that boosts hypothesis formation

A crucial aspect of abduction is the ability to adopt new perspectives [8], which allows clinicians to reinterpret patient information. This reinterpretation can potentially uncover differential diagnoses that were previously overlooked. Importantly, adopting a new perspective aligns closely with the concept of creativity. Thus, when clinicians engage in abduction through the reinterpretation of patient information from new perspectives, they are demonstrating creativity [8] (Figure 1). This point underscores the overlap between creativity and abduction, particularly in diagnostic reasoning. Clinicians sometimes experience a sudden realization of a solution, accompanied by exhilaration of an “Aha! I see!” moment, after being stuck on a problem [9]. In cognitive psychology, this type of problem-solving is referred to as “insight problem-solving” [10]. Since fostering insight requires reinterpreting the problem from a new perspective, insight problem-solving is considered a part of creativity (Figure 1). Therefore, separate and distinct efforts to enhance creativity and insight are unnecessary, as efforts to promote creativity naturally lead to new insights. Insight is always included in creativity. This implies that when diagnostic reasoning reaches a diagnostic reasoning stagnate, efforts to foster creativity may enable the manifestation of insight, allowing new diagnostic hypotheses to be generated at an earlier stage. A shift in perspective can occur through analytical thinking as well as in an unconscious state (which will be discussed later [11], 12]), meaning that creativity and insight can be facilitated by both System 1 and System 2 processes. The type of “new perspective” that is most beneficial varies depending on the case. After hypothesis formation, the next step is hypothesis testing, where new ideas are evaluated to determine whether they lead to a more accurate diagnostic hypothesis. The process of generating specific diagnostic hypotheses involves brainstorming, either individually or collaboratively, to formulate potential hypotheses. Among these, those deemed to have higher plausibility are selected, prioritized, and subsequently tested. If the new idea proves to be more accurate, it confirms that the new perspective was beneficial. In creative thinking, ideas are generated through divergent thinking, while useful ideas are selected through convergent thinking [13]. Hypothesis testing corresponds to the process of convergent thinking.

Figure 1:

Relationship between creativity, insight, abduction, calibration and DPT.

Creativity can be activated in situations of diagnostic reasoning stagnate and in other contexts. Creativity can also aid in the pursuit of successful calibration. To improve diagnosis, the Agency for Healthcare Research and Quality (AHRQ) has proposed a structured series of steps aimed at enhancing calibration (Calibrate Dx: A Resource To Improve Diagnostic Decisions). In this step, clinicians evaluate their clinical practice either independently or with the help of others. To evaluate their thoughts, they need to explore alternative diagnoses or different diagnostic approaches, which essentially means pursuing new perspectives, in alignment with critical thinking. Thus, creativity is essential for improving diagnosis via not only diagnostic thinking processes but also calibration. Calibration can often be achieved through checklists, clinical guidelines, and Bayesian reasoning, but creativity is not equivalent to these. Creativity fundamentally involves generating novel and useful ideas through a shift in perspective, which requires specific methods for facilitating such shifts. Checklists, guidelines, and Bayesian reasoning can also serve as tools to support this process.

Here, we describe an example of the types of hypothesis generation shown in Figure 1. A 52-year-old man presented with chronic episodic chest pain, and the clinician considered angina and gastroesophageal reflux disease (a). However, given that the patient had no history of hypertension, hyperlipidemia, or diabetes, did not experience chest pain during exertion, and did not have symptoms occurring at night, the likelihood of angina was considered low. Additionally, since the patient did not report regurgitation or heartburn, and the symptoms were not more likely to occur after meals, the clinician considered the likelihood of gastroesophageal reflux disease to be low. Recognizing the need to think from a new perspective, the clinician decided to utilize an anatomical approach [14]. This led the clinician to consider the possibility of neuralgia in addition to cardiac and esophageal conditions. Upon further inquiry about exacerbating factors, the patient experienced chest pain when extending the neck. A cervical spine MRI revealed the presence of a cervical disc herniation. When thinking from a new perspective leads to the consideration of neuralgia as a possibility, it corresponds to “b” if no “aha moment” occurs and to “c” if it is accompanied by an “aha moment.” Examples of “d” or “e” include “association.” Whether shifting perspective is genuinely “creative” or simply good thorough reasoning depends on individuals. For example, even in cases where a correct diagnosis can be reached through standard analytical reasoning, an expert clinician who is too fixated on a particular viewpoint may still feel that they have demonstrated creativity or gained insight when they manage to shift their perspective. In fact, it has been suggested that even with the same insight problem, some individuals experience insight while others do not [10]. Formalizing the role of one’s thinking process in diagram form would be reproducible and valuable in reflection. Moreover, as indicated previously, pursuing creativity in diagnostic reasoning can be said to promote “insight” (i) factor, as illustrated in the equation of physicians’ diagnostic reasoning expertise [15].

How can creativity be nurtured in light of cognitive psychology?

Creativity might be misunderstood as something that individuals with specific talents suddenly exhibit without any special effort. Rather, creativity is considered to arise from the functioning of cognitive abilities inherent to humans in general and from interactions among various internal and external factors [3]. Therefore, creativity can be developed and nurtured in several ways.

Discussion

This article re-evaluates diagnostic reasoning in view of creativity, facilitating the generation of additional diagnostic hypotheses, thereby advancing the timeliness and efficiency dimensions of diagnostic excellence.

Methods to promote creativity that are easy to apply in diagnostic reasoning may include metacognition and collaboration with others. However, as mentioned above, many other conditions and methods can promote creativity. It is necessary to verify the beneficial effects of these methods on creativity in diagnostic reasoning. Furthermore, future methods and conditions beyond those mentioned above can be explored.

Limitations of creativity include dependence on new perspectives, variability of individual creativity, and misconception of creativity. First, as creativity inherently relies on adopting new perspectives, it is sometimes challenging for clinicians to develop such perspectives, especially in high-pressure clinical environments. Inexperienced clinicians may struggle to adopt novel viewpoints in many cases. A “new perspective” includes concepts in diagnostic strategies [14], such as an anatomical approach or “weighing anchor” [19], as discussed in the case examples. Therefore, becoming familiar with various diagnostic strategies in daily practice and developing new strategies can facilitate the adoption of “new perspectives” in clinical settings. Inexperienced clinicians need to master a structured approach, which corresponds to the development of routine expertise. Routine experts refine their skills over time through repeated practice, allowing them to perform tasks more efficiently. In contrast, adaptive expertise represents a complementary form of expertise. Adaptive experts fluidly and flexibly access their knowledge networks, adapting to new situations while generating creativity and innovation [32]. In diagnostic reasoning, adaptive expertise is closely related to the concept of creativity introduced in this paper. When faced with complex cases or atypical diseases, clinicians must flexibly reconstruct their existing knowledge and explore diagnoses from new perspectives – an ability that characterizes adaptive expertise. This process inherently requires creative thinking [33]. Therefore, in diagnostic education, it is essential to establish a foundation that fosters routine expertise while gradually incorporating creative approaches to develop adaptive expertise. Adaptive expertise and creativity interact with each other, and as clinicians gain experience and deepen their knowledge, their diagnostic abilities become more flexible and innovative [33].

Second, the propensity for creativity varies widely among individuals and is affected by experience, emotion, or cognitive bias. Therefore, reliance on creativity as a cornerstone of diagnostic reasoning may not yield consistent results across diverse clinicians.

Third, an emphasis on creativity can inadvertently lead to downplaying the importance of evidence-based practice for those medical practitioners who adhere to misconceptions about the secular image evoked by the word creativity. In fact, however, abduction is important in both DPT processes, and the concept of creativity that it encompasses promotes, rather than prevents or downplays, evidence-based practice. For this reason, an accurate understanding by medical practitioners of the definition and existing concepts of creativity described in this paper will be important for the quality of diagnosis. From this point of view, the importance of creativity as described in this paper cannot be ignored.

Conclusions

Creativity serves as a vital driver in diagnostic reasoning, enabling clinicians to generate novel and effective diagnostic hypotheses by adopting new perspectives. Through its inherent connection with abduction and insight, creativity fosters the exploration of alternative diagnostic possibilities, mitigates cognitive biases, and enhances calibration. These qualities underscore its indispensable role in improving diagnosis. This paper highlights the potential of creativity to address diagnostic challenges, offering practical strategies, such as metacognition and collaboration, to nurture creative thinking. However, various limitations, such as the variability in individual creativity, dependence on novel perspective development, and potential for misconceptions stemming from the lay or cultural connotations of the term ‘creativity’, underscore the need for further studies aimed at implementation in clinical practice.