When phy-sicians think about errors in cognitive reasoning, they often focus on the “don’t-miss diagnoses” or the uncommon variant missed by recall or anchoring errors.
“When I reflect on the errors I have made, they mostly fall into the categories that Dr. Groopman describes in his book,” Dr. Feinbloom says. “Interestingly, the errors that I see most often stem from the fear of making an error of omission.”
It is paradoxical, but in order to ensure that no possible diagnosis is missed, doctors often feel the need to rule out all possible diagnoses.
“While it makes us feel that we are doing the best for our patients, this approach leads to an inordinate amount of unnecessary testing and potentially harmful interventions,” says Dr. Feinbloom. “Understanding how cognitive errors occur should allow us to be judicious in our approach, with the confidence to hold back when the diagnosis is clear, and push harder when we know that something does not fit.”
Although many diagnostic errors are attributable to mistakes in thinking, emotions, and feelings—which may not be easy to detect or admit—also contribute to decision-making.
As hypothesized by noted neurologist and author Antonio Damasio in Descartes’ Error: Emotion, Reason, and the Human Brain, some feelings—visceral signals he calls somatic markers—deter us from or attract us to certain images and decisions.6 Remaining cognizant of those feelings helps clarify how they may inform a medical decision—for good and bad.
The emotional dimension of decision-making cannot be disregarded, says Dr. Groopman. “We need to take our emotional temperature; there are patients we like more and patients we like less,” he says. “There are times when we are tremendously motivated to succeed with a very complicated and daunting patient in the hospital, and there are times when we retreat from that for whatever psychological reason. Sometimes it’s fear of failure, sometimes it’s stereotyping. Regardless, we need to have a level of self-awareness.”
The stressful atmosphere of hospital-based medicine contributes to a high level of anxiety. “Physicians use a telegraphic language full of sound bytes with each other that may contribute to the way heuristics are passed from one generation of doctors to the next,” Dr. Groopman says. “That language is enormously powerful in guiding our thinking and the kinds of shortcuts that we use.”