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Licensed Unlicensed Requires Authentication Published by De Gruyter October 24, 2019

Thresholds, rules and defensive strategies: how physicians learn from their prior diagnosis-related experiences

  • Norbert Donner-Banzhoff ORCID logo EMAIL logo , Beate Müller , Martin Beyer , Jörg Haasenritter and Carola Seifart
From the journal Diagnosis



Health professionals are encouraged to learn from their errors. Determining how primary care physicians (PCPs) react to a case, in which their original diagnosis differed from the final outcome, could provide new insights on how they learn from experiences. We explored how PCPs altered their diagnostic evaluation of future patients after cases where the originally assumed diagnosis turned out to be wrong.


We asked German PCPs to complete an online survey where they described how the patient concerned originally presented, the subsequent course of events and whether they would change their diagnostic work-up of future patients. Qualitative methods were used to analyze narrative text obtained by this survey.


A total of 29 PCPs submitted cases, most of which were ultimately found to be more severe than originally assumed. PCPs (n = 27) reflected on changes to their subsequent clinical decisions in the form of general maxims (n = 20) or more specific rules (n = 11). Most changes would have resulted in a lower threshold for investigations, referral and/or a more extensive collection of diagnostic information. PCPs decided not only to listen more often to their intuition (gut feelings), but to also practice more analytical reasoning. Participants felt the need for change of practice even if no clinical standards had been violated in the diagnosis of that case. Some decided to resort to defensive strategies in the future.


We describe mechanisms by which physicians calibrate their decision thresholds, as well as their cognitive mode (intuitive vs. analytical). PCPs reported the need for change in clinical practice despite the absence of error in some cases.

Corresponding author: Prof. Norbert Donner-Banzhoff, MD, MHSc, Department of Family Medicine (Allgemeinmedizin), University of Marburg, Karl-von-Frisch-Str. 4, 35043 Marburg, Germany


We would like to thank Juliette Rautenberg for providing English-language editing, improving the precision and fluency of the manuscript.

  1. Author contributions: All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

  2. Research funding: None declared.

  3. Employment or leadership: None declared.

  4. Honorarium: None declared.


1. Kohn LT, Corrigan J, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000 (Quality Chasm Series).Search in Google Scholar

2. Bunting RF, Groszkruger DP. From to err is human to improving diagnosis in health care: the risk management perspective. J Healthc Risk Manag 2016;35:10–23.10.1002/jhrm.21205Search in Google Scholar PubMed

3. Croskerry P. Context is everything or how could I have been that stupid? Healthc Q 2009;12 Spec No Patient:6.10.12927/hcq.2009.20945Search in Google Scholar PubMed

4. Woods DD, Cook RI. Nine steps to move forward from error. Cogn Technol Work 2002;4:137–44.10.1007/s101110200012Search in Google Scholar

5. Olson AP, Graber ML, Singh H. Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events. J Gen Intern Med 2018;33:1187–91.10.1007/s11606-018-4304-2Search in Google Scholar PubMed PubMed Central

6. Beyer M, Blazejewski T, Güthlin C, Klemp K, Wunder A, Hoffmann B, et al. Das hausärztliche Fehlerberichts- und Lernsystem ‘’ – Berichtsbestand und Nutzungsperspektiven. Z Evid Fortbild Qual Gesundhwes 2015;109:62–8.10.1016/j.zefq.2014.06.013Search in Google Scholar PubMed

7. Donner-Banzhoff N. Der Pseudofehler in der Medizin – paradoxe Gefährdungen für Patienten. Z Allg Med 2014;90:200–6.Search in Google Scholar

8. Zwaan L, Singh H. The challenges in defining and measuring diagnostic error. Diagnosis 2015;2:97–103.10.1515/dx-2014-0069Search in Google Scholar PubMed PubMed Central

9. Hofer TP, Kerr EA, Hayward RA. What is an error? Eff Clin Pract 2000;3:261–9.Search in Google Scholar

10. LimeSurvey [cited 2018 Mar 11]. Available from: URL: in Google Scholar

11. Sandelowski M, Barroso J. Classifying the findings in qualitative studies. Qual Health Res 2003;13:905–23.10.1177/1049732303253488Search in Google Scholar PubMed

12. Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook, 3rd ed. Thousand Oaks, CA, USA: SAGE Publications, Inc., 2014.Search in Google Scholar

13. Sox HC. Medical decision making. Philadelphia: American College of Physicians, 2007.Search in Google Scholar

14. Enzyklopädie Philosophie und Wissenschaftstheorie. [Darmstadt]: Wiss. Buchges, 2013.Search in Google Scholar

15. Bösner S, Haasenritter J, Becker A, Karatolios K, Vaucher P, Gencer B, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. Can Med Assoc J 2010;182:1295–300.10.1503/cmaj.100212Search in Google Scholar PubMed PubMed Central

16. Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med 1980;302:1109–17.10.1056/NEJM198005153022003Search in Google Scholar PubMed

17. Vickers AJ, Elkin EB. Decision curve analysis: a novel method for evaluating prediction models. Med Decis Making 2006;26:565–74.10.1177/0272989X06295361Search in Google Scholar PubMed PubMed Central

18. Tsalatsanis A, Hozo I, Vickers A, Djulbegovic B. A regret theory approach to decision curve analysis: a novel method for eliciting decision makers’ preferences and decision-making. BMC Med Inform Decis 2010;10:51.10.1186/1472-6947-10-51Search in Google Scholar

19. Mazzocco K, Cherubini P. The effect of outcome information on health professionals’ spontaneous learning. Med Educ 2010;44:962–8.10.1111/j.1365-2923.2010.03744.xSearch in Google Scholar

20. Swets JA, Dawes RM, Monahan J. Psychological science can improve diagnostic decisions. Psychol Sci Public Interest 2000;1:1–26.10.1111/1529-1006.001Search in Google Scholar

21. André M, Borgquist L, Foldevi M, Molstad S. Asking for ‘rules of thumb’: a way to discover tacit knowledge in general practice. Fam Pract 2002;19:617–22.10.1093/fampra/19.6.617Search in Google Scholar

22. Stolper E, van de Wiel M, van Royen P, van Bokhoven M, van der Weijden T, Dinant GJ. Gut feelings as a third track in general practitioners’ diagnostic reasoning. J Gen Intern Med 2011;26:197–203.10.1007/s11606-010-1524-5Search in Google Scholar

23. Stolper E, van Royen P, Dinant GJ. The ‘sense of alarm’ (‘gut feeling’) in clinical practice. A survey among European general practitioners on recognition and expression. Eur J Gen Pract 2010;16:72–4.10.3109/13814781003653424Search in Google Scholar

24. Roberts A, James J, Dhatariya K. Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy; October 2014. Available from: URL: in Google Scholar

25. Klingman D, Localio AR, Sugarman J, Wagner JL, Polishuk PT, Wolfe L, et al. Measuring defensive medicine using clinical scenario surveys. J Health Polit Policy Law 1996;21:185–220.10.1215/03616878-21-2-185Search in Google Scholar

26. Balogh E, Miller BT, Ball J. Improving diagnosis in health care. Washington, DC: The National Academies Press, 2015. (Quality Chasm Series).10.17226/21794Search in Google Scholar

27. Kassirer JP, Kopelman RI. Cognitive errors in diagnosis: instantiation, classification, and consequences. Am J Med 1989;86:433–41.10.1016/0002-9343(89)90342-2Search in Google Scholar

28. Goyder CR, Jones CH, Heneghan CJ, Thompson MJ. Missed opportunities for diagnosis: lessons learned from diagnostic errors in primary care. Br J Gen Pract 2015;65:e838–44.10.3399/bjgp15X687889Search in Google Scholar PubMed PubMed Central

29. Barraclough K. New NICE guidance on referral for cancer. Br Med J 2015;351:h3640.10.1136/bmj.h3640Search in Google Scholar

30. Hautz WE, Kämmer JE, Hautz SC, Sauter TC, Zwaan L, Exadaktylos AK, et al. Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room. Scand J Trauma Resusc Emerg Med 2019;27:54.10.1186/s13049-019-0629-zSearch in Google Scholar

31. Eames J, Eisenman A, Schuster RJ. Disagreement between emergency department admission diagnosis and hospital discharge diagnosis: mortality and morbidity. Diagnosis 2016;3:23–30.10.1515/dx-2015-0028Search in Google Scholar

32. Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DR. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med 2012;87:149–56.10.1097/ACM.0b013e31823f71e6Search in Google Scholar

33. Singh H. Editorial: Helping organizations with defining diagnostic errors as missed opportunities in diagnosis: diagnostic error. Jt Comm J Qual Patient Saf 2014;40:99–101.10.1016/S1553-7250(14)40012-6Search in Google Scholar

34. Waterman AD, Garbutt J, Hazel E, Dunagan WC, Levinson W, Fraser VJ, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76.10.1016/S1553-7250(07)33050-XSearch in Google Scholar

Supplementary Material

The online version of this article offers supplementary material (

Received: 2019-03-22
Accepted: 2019-09-23
Published Online: 2019-10-24
Published in Print: 2020-05-26

©2020 Walter de Gruyter GmbH, Berlin/Boston

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