By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“We’re blind to our blindness. We have very little idea of how little we know. We’re not designed to know how little we know.”

-Daniel Kahneman, Nobel Laureate in Economics

Regular readers of this newsletter will recall a series of lead articles on improving diagnostic accuracy (Parts I, II, and III found on our phcprimarycare.org blog). Medical schools, residencies and continuing medical education programs have recently adopted some formal training in critical thinking, including how to understand how cognitive biases can lead to mistaken diagnoses. This takes the principles of behavioral economics, based on the pioneering work of Psychologist Daniel Kahneman (summarized for a general audience in his most famous book, Thinking Fast and Slow), and helps us understand how physicians think and make mistakes.

In the January 25, 2022 JAMA, Dr. Pat Croskerry provided a succinct summary of recommendations for overcoming these biases to become a “rational diagnostician.”

1. Establish Awareness of How Cognition Works. Understand the most common cognitive biases and the difference between type 1 (intuitive/fast) and type 2 (analytical/slow) processing.
2. Teach and Coach Critical Thinking. Excellent coaching promotes deep learning, allowing 10-fold faster development of expertise. Understanding the mechanism of deep learning can help those of us without ready coaches to improve our mastery of complex areas of expertise. The book The Talent Code, provides the best overview of this topic.
3. Make the Work Environment More Conducive to Sound Thinking. Three main conditions that interfere with analytical thinking include:
   1. Psychological stress leading to anxiety and dysphoria,
   2. Sleep deprivation causing chronic fatigue, and
   3. Excessive cognitive loading (responding to a barrage of emails and tasks without time to pause and reflect).
4. Circumvent Type 1 Distortion. Setting up mental steps and processes to allow “executive override” to pause and reflect on the possibility that our intuitive initial impression is incorrect, and evaluating possible alternative explanations or decisions. For example, when a patient’s clinical presentation has some findings that are not explained by our initial, presumptive diagnosis, we pause to consider what else might explain this. For example: “Is this recurrent pharyngitis a sign of an underlying immune compromise?”
5. Expand Individual Expertise. While routine expertise is developed with training and practice, adaptive expertise encourages flexibility and innovation in problem-solving. Adaptive expertise is fueled by curiosity; it develops when exploring the possibilities raised with type 2 thinking, and also by regularly reading journal articles or exploring topics that are unrelated to any particular patient.
6. Promote Team Cognition. Regular conferring with colleagues on challenging diagnostic or therapeutic situations brings a collective expertise to bear, which can produce better outcomes for your patients. While synchronous consultation (for example “curbside consultation”) allows some back and forth, and is quicker, asynchronous consultation (for example using eConsult or secure email) allows time for more nuance and detail to be included and more analytic thinking and background research to be done.
7. Mitigate Judgment and Decision-making Fatigue. Dr. Croskerry suggests the use of “cognitive forcing strategies,” like adopting clinical maxims such as “rule out worst-case scenario,” practices such as routinely documenting a differential diagnosis, or always using a pre-operative checklist.

The common feature of these approaches is that they will require an intentionality derived from a sense of professionalism. It is essential for clinical leaders to find ways nurture these habits for those on our teams.