I’ve Been Framed!

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.

Making a correct diagnosis is the central cognitive endeavor of every clinician, since an accurate diagnosis usually leads to appropriate treatment. As PAs and NPs, we dread missing a diagnosis: jaw pain that turns out to be angina or back pain that ends up being an aortic aneurysm. And then of course, there are preventable infections and medication errors.

Several studies in the medical literature indicate that misdiagnosis occurs in 15% to 20% of all cases; in half of these, the patient is harmed. The vast majority of misdiagnoses, about 80%, are due to cognitive errors—in other words, errors in thinking!

This was recently brought home to me through an online course required by my malpractice insurance carrier. The focus was cognitive errors in diagnosis. Prior to starting, I expected it to be a no brainer. After all, every clinician knows what malpractice entails and how best to avoid it, right? We have attended CME courses and read plenty of articles on the topic.

Well, this course was different and had a rather sobering effect on me. As a result, I started to ponder the process we go through to establish a diagnosis.

For the most part, formulating a diagnosis is largely subconscious, and our ability to do it increases with experience.¹ The normative model is Bayes’ theorem, an application of conditional probabilities. Clinicians use information on the prevalence of various clinical features in different disease entities to determine the probability that a particular condition is present. The theorem is considered a milestone in logical reasoning and a conquest of statistical inference, although it is still treated with suspicion by most clinicians.

What makes this method potentially impractical is the complexity of the calculations and the fact that not all required information may be readily available. Would you agree that it is impossible to search for and consider all required information or evaluate all possible hypotheses? Therefore, the search for the correct clinical diagnosis is limited to satisfactory explanations within the constraints of the clinical environment.²

Another model for clinical diagnosis is the hypothetico-deductive model. Clinicians achieve a diagnosis by generating multiple competing hypotheses from initial patient cues and collecting data to confirm or refute each. This model has been validated through empirical studies.³ Most clinicians, in my experience, use a combination of intuitive, reflective, and analytical problem solving, with some approaches given more emphasis than others.

On the next page: Categories of diagnostic errors >>

According to Graber et al⁴, diagnostic errors fall into three categories:

“No-Fault” Errors: The illness is silent, masked, or unusual in its presentation, or the patient misrepresents symptoms.

System-Related: This includes erroneous information in the patient record, technical and/or equipment failures, incorrect test results, poor coordination, and organizational flaws.

Cognitive: Herein lies faulty data collection, interpretation/reasoning, or incomplete knowledge on the part of the clinician. The information necessary to draw the right conclusion is available, or easily found, but the wrong conclusion is reached.⁴

What really intrigued me is the cognitive framing effect. This is when the diagnosis is unduly influenced by collateral information. There is considerable evidence that we make irrational or biased decisions based on how the expected outcome is framed.

Shortly after taking the malpractice course, I was working in an allergy and asthma practice and had an immunotherapy patient on my schedule who was listed as “same day/sick.” I entered the room thinking her symptoms could be related to her allergic rhinitis or extrinsic asthma or perhaps an adverse reaction to that week’s allergy shot. What I found was a 38-year-old woman with a three-day history of a 103°F fever, severe neck pain, headache, and severe malaise. Sparing all other information, suffice it to say she was sent directly to the emergency department (ED), where she was admitted. 

I am also aware of a case in which a patient with shortness of breath was treated in an ED with an erroneous diagnosis of COPD with a “long-standing benign murmur.” She was in a room with nebulizers on the nightstand and a diagnosis of “COPD ­exacerbation” and later died of aortic stenosis. Sometimes, inaccurate prior information or collateral evidence frames a problem as pulmonary when it is really cardiac.

Essentially, clinicians may be influenced by the way in which the problem is framed. For example, perceptions of risk to the patient may be influenced by the possible outcome (eg, is the patient likely to die?), the type of clinic, or even the time of day.⁵ Framing may also occur when another clinician presents a case to you that is influenced by his or her own bias.

On the next page: How to avoid framing bias >>

There are some remedies to avoid framing bias:

• Acknowledge that framing bias may exist, and be on the lookout for it.

• Improve your knowledge and experience through use of simulations, improved feedback on decision outcomes, and focused CME on known pitfalls in specific diseases/scenarios.

• Improve your clinical reasoning through reflective practices. Slow down (easy for me to say) and think. Perform a metacognitive review, and recognize the traps associated with relying on rules-of-thumb.

• Provide cognitive help through technological support and algorithms (eg, through electronic medical record prompts), and ensure access to second opinions from colleagues.

• Reduce the “cognitive load” by modifying work schedules and the number of patients to be seen. Reduce distractions and interruptions in the work environment.⁶

With the time constraints and frenzied nature of modern health care, there is, I believe, value in stopping to reflect on our thinking, particularly when an original presumption about a diagnosis appears not to succeed in explaining the complaint or empiric therapy does not improve the patient’s symptoms. At these times, drawing on both intuitive and deliberative thinking can be fundamental in avoiding thought traps and moving us onto a better diagnostic path.

I have not meant to oversimplify an obviously complex topic, but I would love to hear from you on your opinion about this topic. Contact me at [email protected].

REFERENCES

1. Nkanginieme KEO. Clinical diagnosis as
a dynamic cognitive process: application
of Bloom’s taxonomy for educational objectives in the cognitive domain. Med Educ Online [serial online]. 1997;2:1. www.msu.edu/~dsolomon/f0000007.pdf. Accessed May 14, 2014.

2. Phua DH, Tan NC. Cognitive aspect of diagnostic errors. Ann Acad Med Singapore. 2013; 42(1):33-41.

3. Charlin B, Tardif J, Boshuizen HP. Scripts and medical diagnostic knowledge: theory and applications for clinical reasoning instruction and research. Acad Med. 2000;75(2):182-190.

4. Graber ML, Franklin N, Gordoin R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

5. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.

6. Perkocha L. Cognitive error in medical diagnosis: what we now know. Presented at University of Hawaii John A Burns School of Medicine Reunion, July 27, 2013. https://jabsom.hawaii.edu/JABSOM/departments/CME/doc/Perkocha.pdf. Accessed May 14, 2014.  5, 2014.