Diagnostic Failure: A Cognitive and Affective Approach

Diagnosis is the foundation of medicine. Effective treatment cannot begin until an accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of clinical performance. It is vulnerable to a variety of failings, the most prevalent arising through cognitive and affective influences. The impact of diagnostic failure on patient safety does not appear to have been fully recognized. Ideally, all information used in diagnostic reasoning is objective and all thinking is logical and valid, but these conditions are not always met. Two major phenomena that may undermine objectivity and rational thinking are cognitive dispositions to respond (CDRs) and affective dispositions to respond (ADRs) toward the patient. In this report, the determinants and characteristics of the major CDRs and ADRs are reviewed, as are a variety of de-biasing strategies that may mitigate their influence. A retrospective analytical process, the cognitive and affective autopsy, is also described. The purpose of this report is to provide insight into cognitive and affective influences that have resulted in delayed or missed diagnoses. Background The turn of the 20 century was a watershed in medical education reform. Students came to be regarded less as “memorizers” and more as “thinkers,” and this signaled the beginning of cognitive science’s influence on medical training. That influence has continued to grow. Medicine has assimilated many of the key constructs from the cognitive revolution that occurred in psychology over the last 30 years of the 20 century. Some are incorporated into the most recent of medical education models, the Clinical Presentation (CP) Curriculum, developed at the University of Calgary in the early 1990s. This hierarchically structured schematic approach provides an overarching cognitive strategy for both learning and organizing knowledge, as well as a framework for establishing a differential diagnosis. With disease, injury, or illness, the diagnosis is often obvious and may involve no more than simple pattern recognition. Where there is uncertainty, however, there is a need for clinical reasoning and decisionmaking; both of these processes show considerable vulnerability to error. Benchmark studies on medical error found diagnostic failure more common in the three disciplines in which diagnostic uncertainty appears to be the highest: internal, family, and emergency medicine. Inevitably, these shortcomings are reflected in litigation. Two-thirds of completed claims against family practitioners in the United Kingdom were attributed to delays in diagnosis and treatment, and “failure to diagnose” accounted for Report Documentation Page Form Approved OMB No. 0704-0188 Public reporting burden for the collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Washington Headquarters Services, Directorate for Information Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to a penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.