Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter September 20, 2021

Narrowing the mindware gap in medicine

Pat Croskerry
From the journal Diagnosis

Abstract

Medical error is now recognized as one of the leading causes of death in the United States. Of the medical errors, diagnostic failure appears to be the dominant contributor, failing in a significant number of cases, and associated with a high degree of morbidity and mortality. One of the significant contributors to diagnostic failure is the cognitive performance of the provider, how they think and decide about the process of diagnosis. This thinking deficit in clinical reasoning, referred to as a mindware gap, deserves the attention of medical educators. A variety of specific approaches are outlined here that have the potential to close the gap.


Corresponding author: Pat Croskerry, Emergency Medicine, Dalhousie University, Halifax, Canada, E-mail:

  1. Research funding: None declared.

  2. Author contributions: I am the sole author and accept responsibility for the entire content of this manuscript and approve its submission.

  3. Competing interests: None declared.

  4. Informed consent: Not applicable.

  5. Ethical approval: Not applicable.

References

1. Makary, MA, Daniel, M. Medical error-the third leading cause of death in the US. Br Med J 2016;353:i2139. https://doi.org/10.1136/bmj.i2139.Search in Google Scholar PubMed

2. Singh, H, Meyer, AN, Thomas, EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Qual Saf 2014;23:727–31. https://doi.org/10.1136/bmjqs-2013-002627.Search in Google Scholar PubMed PubMed Central

3. Saber Tehrani, AS, Lee, H, Mathews, SC, Shore, A, Makary, MA, Pronovost, PJ, et al.. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank. BMJ Qual Saf 2013;22:672–80. https://doi.org/10.1136/bmjqs-2012-001550.Search in Google Scholar PubMed

4. Graber, ML, Franklin, N, Gordon, RR. Diagnostic error in internal medicine. Arch Intern Med 2005;165:1493–9. https://doi.org/10.1001/archinte.165.13.1493.Search in Google Scholar PubMed

5. Berner, ES, Graber, ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 Suppl):S2–23.https://doi.org/10.1016/j.amjmed.2008.01.001.Search in Google Scholar PubMed

6. Leape, L, Berwick, D, Bates, D. Counting deaths from medical errors. J Am Med Assoc 2002;288:2405. https://doi.org/10.1001/jama.288.19.2405-jlt1120-2-3.Search in Google Scholar

7. Winters, B, Custer, JW, Galvago, SM, Colantuoni, E, Kapoor, SG, Lee, H, et al.. Diagnostic errors in the intensive care unit: a systematic review of autopsy studies. BMJ Qual Saf 2012;21:894–902. https://doi.org/10.1136/bmjqs-2012-000803.Search in Google Scholar PubMed

8. Schneider, W, Shiffrin, RM. Controlled and automatic human information processing: 1. Detection, search, and attention. Psychol Rev 1977;84:1–66. https://doi.org/10.1037/0033-295x.84.1.1.Search in Google Scholar

9. Dawson, NV. Physician judgment in clinical settings: methodological influences and cognitive performance. Clin Chem 1993;39:1468–80. https://doi.org/10.1093/clinchem/39.7.1468.Search in Google Scholar

10. Croskerry, P. A universal model for diagnostic reasoning. Acad Med 2009;84:1022–8. https://doi.org/10.1097/acm.0b013e3181ace703.Search in Google Scholar PubMed

11. Stanovich, KE. Rationality and the reflective mind. New York: Oxford University Press; 2011:19–22 pp.10.1093/acprof:oso/9780195341140.001.0001Search in Google Scholar

12. Dreyfus, S. The five-stage model of adult skills acquisition. Bull Sci Technol Soc 2004;24:177–9. https://doi.org/10.1177/0270467604264992.Search in Google Scholar

13. Hatano, G, Inagaki, K. Two courses of expertise. In: Stevenson, H, Azuma, H, Hakuta, K, editors. Child development and education in Japan. New York: Freeman; 1986:262–72 pp.Search in Google Scholar

14. Croskerry, P. Adaptive expertise in medical decision making. Med Teach 2018;40:803–8. https://doi.org/10.1080/0142159x.2018.1484898.Search in Google Scholar PubMed

15. Stanovich, KE. Rational and irrational thought: the thinking that IQ tests miss. Sci Am Mind 2009;20:34–9. https://doi.org/10.1038/scientificamericanmind1109-34.Search in Google Scholar

16. Stanovich, K. What intelligence tests miss: the psychology of rational thought. New Haven, CT: Yale University Press; 2009.Search in Google Scholar

17. Hicks, NM, Bumbaco, AE, Douglas, EP. Critical thinking, reflective practice, and adaptive expertise in engineering. Paper presented at ASEE Annual Conference and Exposition, Indianapolis, Indiana; 2014.10.18260/1-2--20233Search in Google Scholar

18. Stanovich, KE, West, RF, Toplak, ME. Intelligence and rationality. In: Sternberg, R, Kaufman, SB, editors. Cambridge handbook of intelligence, 3rd ed. Cambridge, UK: Cambridge University Press; 2012:784–826 pp.10.1017/CBO9780511977244.040Search in Google Scholar

19. Stanovich, KE, West, RF. What intelligence tests miss. Psychol 2014;27:80–3.10.12987/9780300142532Search in Google Scholar

20. Romeo, R. Platonically irrational. In: Haselby, S, editor. Aeon. Aeon Media Group; 2017.Search in Google Scholar

21. List of cognitive biases. Available from: https://en.wikipedia.org/wiki/List_of_cognitive_biases#Debiasing [Accessed 17 Jul 2021].Search in Google Scholar

22. Benson, B. Cognitive bias cheat sheet. Available from: https://betterhumans.coach.me/cognitive-bias-cheat-sheet-55a472476b18 [Accessed 27 Dec 2018].Search in Google Scholar

23. Croskerry, P. The cognitive autopsy: a root cause analysis of thinking failures in medicine. New York: Oxford University Press; 2020.10.1093/med/9780190088743.001.0001Search in Google Scholar

24. Croskerry, P. Bias: a normal operating characteristic of the diagnosing brain. Diagnosis (Berl). 2014;1:23–7. https://doi.org/10.1515/dx-2013-0028.Search in Google Scholar PubMed

25. Tversky, A, Kahneman, D. Judgment under uncertainty: heuristics and biases. Science 1974;185:1124–31. https://doi.org/10.1126/science.185.4157.1124.Search in Google Scholar PubMed

26. Tetlock, PE, Mellers, B. The great rationality debate. Psychol Sci 2002;13:94–9. https://doi.org/10.1111/1467-9280.00418.Search in Google Scholar

27. Stanovich, KE. How to think rationally about world problems. J Intell 2018;6:25. https://doi.org/10.3390/jintelligence6020025.Search in Google Scholar PubMed PubMed Central

28. Croskerry, P. A model for clinical decision making in medicine. Med Sci Educ 2017;27(1 Suppl):9–13.https://doi.org/10.1007/s40670-017-0499-9.Search in Google Scholar

29. Croskerry, P. Cognitive bias mitigation: becoming better diagnosticians. In: Croskerry, P, Cosby, K, Graber, M, Singh, H, editors. Diagnosis: interpreting the shadows. Boca Raton, Fla: CRC Taylor and Francis Group; 2017:257–87 pp.10.1201/9781315116334-21Search in Google Scholar

30. Ludolph, R, Schulz, PJ. Debiasing health-related judgments and decision making: a systematic review. Med Decis Making 2018;38:3–13. https://doi.org/10.1177/0272989x17716672.Search in Google Scholar PubMed

31. Epstein, R. Attending. Medicine, mindfulness, and humanity. New York: Scribner; 2017.Search in Google Scholar

32. Sibinga, EM, Wu, AW. Clinician mindfulness and patient safety. J Am Med Assoc 2010;304:2532–3. https://doi.org/10.1001/jama.2010.1817.Search in Google Scholar PubMed

33. Schon, DA. The reflective practitioner: how professionals think in action. New York: Basic Books; 1983.Search in Google Scholar

34. Croskerry, P. The rational diagnostician. In: Croskerry, P, Cosby, K, Graber, M, Singh, H, editors. Diagnosis: interpreting the shadows. Boca Raton, Fla: CRC Taylor and Francis Group; 2017:113–28 pp.10.1201/9781315116334-8Search in Google Scholar

35. The Foundation for Critical Thinking. Developing as rational persons: viewing our development in stages. Available from: http://www.criticalthinking.org/pages/developing-as-rational-persons-viewing-ourdevelopment-in-stages/518 [Accessed 17 Oct 2019].Search in Google Scholar

36. Royce, CS, Hayes, MM, Schwartzstein, RM. Teaching critical thinking: a case for instruction in cognitive biases to reduce diagnostic errors and improve patient safety. Acad Med 2019;94:187–94. https://doi.org/10.1097/acm.0000000000002518.Search in Google Scholar

37. Halpern, DF. The nature and nurture of critical thinking. In: Sternberg, RJ, Roediger, HL III, Halpern, DF, editors. Critical thinking in psychology. New York: Cambridge University Press; 2007:1–14 pp.10.1017/CBO9780511804632.002Search in Google Scholar

38. Ennis, RH. Critical thinking across the curriculum (CTAC). OSSA Conference Archive; 2013. Available from: https://scholar.uwindsor.ca/ossaarchive/OSSA10/papersandcommentaries/44.Search in Google Scholar

39. Nisbett, RE, Fong, GT, Lehman, DR, Cheng, PW. Teaching reasoning. Science 1987;238:625–31. https://doi.org/10.1126/science.3672116.Search in Google Scholar PubMed

40. Rubinstein, MF, Firstenberg, IR. Tools for thinking. In: Stice, JE, editor. Developing critical thinking and problem solving abilities. New directions for teaching and learning. San Francisco: Jossey-Bass; 1987:23–36 pp.10.1002/tl.37219873004Search in Google Scholar

41. Woods, DR. How might I teach problem solving? In: Stice, JE, editor. Developing critical thinking and problem solving abilities. New directions for teaching and learning. San Francisco: Jossey-Bass; 1987:55–71 pp.10.1002/tl.37219873006Search in Google Scholar

42. Nisbett, RE. Rules for reasoning. Hillsdale, NJ: Erlbaum; 1993.Search in Google Scholar

43. Higgins, S, Hall, E, Baumfield, V, Moseley, D. A meta-analysis of the impact of the implementation of thinking skills approaches on pupils; 2005. Available from: https://eppi.ioe.ac.uk/cms/Default.aspx?tabid=339 [Accessed 24 Jan 2019].Search in Google Scholar

44. Twardy, CR. Argument maps improve critical thinking. Teach Philos 2004;27:95–116. https://doi.org/10.5840/teachphil200427213.Search in Google Scholar

45. Van Gelder, T, Bissett, M, Cumming, G. Cultivating expertise in informal reasoning. Can J Exp Psychol 2004;58:142–52. https://doi.org/10.1037/h0085794.Search in Google Scholar PubMed

46. Solon, T. Generic critical thinking infusion and course content learning in introductory psychology. J Instr Psychol 2007;34:95–109.Search in Google Scholar

47. Abrami, PC, Bernard, RM, Borokhovski, E, Waddington, DI, Wade, CA, Persson, T. Strategies for teaching students to think critically: a meta-analysis. Rev Educ Res 2014;85:275–314.10.3102/0034654314551063Search in Google Scholar

48. Self, DJ. The educational philosophies behind the medical humanities programs in the United States: an empirical assessment of three different approaches to humanistic medical education. Theor Med 1993;14:221–9. https://doi.org/10.1007/bf00995164.Search in Google Scholar

49. Fodor, J. Look! Lond Rev Books 1998;20:21–9. https://doi.org/10.1111/j.1467-9639.1998.tb00786.x.Search in Google Scholar

50. Wilson, EO. Consilience: the unity of knowledge. New York: Vintage Books; 1998.Search in Google Scholar

51. Forgeard, M, Winner, E, Norton, A, Schlaug, G. Practicing a musical instrument in childhood is associated with enhanced verbal ability and nonverbal reasoning. PLoS One 2008;3:1–8. https://doi.org/10.1371/journal.pone.0003566.Search in Google Scholar PubMed PubMed Central

52. Barrett, KC, Ashley, R, Strait, DL, Kraus, N. Art and science: how musical training shapes the brain. Front Psychol 2013;4:1–13. https://doi.org/10.3389/fpsyg.2013.00713.Search in Google Scholar PubMed PubMed Central

53. Zazulak, J, Sanaee, M, Frolic, A, Knibb, N, Tesluk, E, Hughes, E, et al.. The art of medicine: arts-based training in observation and mindfulness for fostering the empathic response in medical residents. Med Humanit 2017;43:192–8. https://doi.org/10.1136/medhum-2016-011180.Search in Google Scholar PubMed

54. Di Blasi, Z, Harkness, E, Ernst, E, Georgiou, A, Kleijnen, J. Influence of context effects on health outcomes: a systematic review. Lancet 2001;357:757–62. https://doi.org/10.1016/s0140-6736(00)04169-6.Search in Google Scholar

55. Rakel, D, Barrett, B, Zhang, Z, Hoeft, T, Chewning, B, Marchand, L, et al.. Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ Counsel 2011;85:390–7. https://doi.org/10.1016/j.pec.2011.01.009.Search in Google Scholar PubMed PubMed Central

56. Naghshineh, S, Hafler, JP, Miller, AR, Blanco, MA, Lipsitz, SR, Dubroff, RP, et al.. Formal art observation training improves medical students’ visual diagnostic skills. J Gen Intern Med 2008;23:991–7. https://doi.org/10.1007/s11606-008-0667-0.Search in Google Scholar PubMed PubMed Central

57. De Bono, E. Lateral thinking: a textbook of creativity. London: Penguin Life; 1991.Search in Google Scholar

58. Emmett, KR. Nonspecific and atypical presentation of disease in the older patient. Geriatrics 1998;53:50–60.Search in Google Scholar

59. Croskerry, P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med 2003;78:775–80. https://doi.org/10.1097/00001888-200308000-00003.Search in Google Scholar PubMed

60. Fiske, ST, Taylor, SE. Social cognition, 2nd ed. New York: McGraw-Hill; 1991.Search in Google Scholar

61. Kahneman, D. Thinking fast and slow. New York: Farrar. Straus and Giroux; 2011.Search in Google Scholar

62. National Academies of Sciences. Engineering, and medicine. Improving diagnosis in health care. Washington, DC: The National Academies Press; 2015.Search in Google Scholar

63. Croskerry, P. ED Cognition: any decision by anyone at any time. ED administration series. Can J Emerg Med 2014;16:13-9. https://doi.org/10.2310/8000.2013.131053.Search in Google Scholar PubMed

64. Smith, MW, Hughes, AM, Brown, C, Russo, E, Giardina, TD, Mehta, P, et al.. Test results management and distributed cognition in electronic health record–enabled primary care. Health Inf J 2018:1–14.10.1177/1460458218779114Search in Google Scholar PubMed

65. Allen, PM, Edwards, JA, Snyder, FJ, Makinson, KA, Hmby, DM. The effect of cognitive load on decision making with graphically displayed uncertainty information. Risk Anal 2014;34:1495–505. https://doi.org/10.1111/risa.12161.Search in Google Scholar PubMed PubMed Central

66. Hogarth, R. Educating intuition. Chicago, IL: University of Chicago Press; 2001.Search in Google Scholar

Received: 2020-10-10
Accepted: 2021-08-23
Published Online: 2021-09-20

© 2021 Walter de Gruyter GmbH, Berlin/Boston