The Complex Role of Clinical Judgment in Diagnostic Errors
Laura M. Cascella, MA, CPHRM
Errors in diagnosis represent a serious threat to patient safety as well as a significant medical liability concern. MedPro Group closed malpractice claims data show that diagnosis-related allegations occur across all specialties and healthcare locations. Analysis of the risk factors that contribute to these allegations shows that clinical judgment is, by far, the most prevalent.1
Clinical judgment refers to the thought process (clinical reasoning) that allows healthcare providers to arrive at a conclusion (clinical decision-making) based on objective and subjective information about a patient. An article in the Journal of Evaluation in Clinical Practice explains that “Clinical judgment is developed through practice, experience, knowledge and continuous critical analysis.”2
Clinical judgment can involve both automatic, intuitive reasoning and analytic, reflective reasoning. These types of reasoning are not mutually exclusive; they can occur in tandem, and healthcare providers might switch their judgment strategy based on the circumstances they encounter. Because the cognitive processes involved in clinical judgment are complex, they are prone to various cognitive errors, such as faulty heuristics/cognitive biases and affective influences/situativity.3
Faulty Heuristics and Cognitive Biases
The term “heuristics” refers to mental shortcuts in the thought process that help conserve time and effort. These shortcuts are an essential part of thinking, but they also are prone to errors. Cognitive biases occur when heuristics lead to faulty decision-making.4 Some common biases include those listed below:
- Anchoring refers to a tendency to “anchor” to, or rely too much on, a particular piece of information — often the initial information obtained, the first symptom, or the first lab abnormality.
- Under-adjustment is the inability to revise a diagnosis based on additional clinical data.
- Premature closure refers to the termination of the data-gathering process (e.g., patient history, family history, and medication list) before all of the information is known.
- Primacy effect, similar to anchoring, refers to a tendency to show bias toward initial information.
- Confirmation refers to the tendency to focus on information that confirms an initial diagnosis or to manipulate information to fit preconceptions.
- Availability can occur if a clinician considers a diagnosis more likely because it is forefront in his/her mind. Past experience and recent, frequent, or prominent cases can all play a role in availability bias.
- Overconfidence refers to an overestimation of an individual’s own knowledge and skill, as well as an inability to identify knowledge gaps. Overconfidence bias might result from a lack of feedback related to diagnostic accuracy, which may in turn cause clinicians to overestimate their diagnostic precision. To this point, researchers suggest that overconfidence might increase as a doctor’s level of expertise increases.5
Affective Influences
Whereas cognitive biases are lapses in thinking, the term “affective influences” refers to emotions and feelings that can sway clinical judgment.6 Preconceived notions and stereotypes about a patient might influence how a healthcare provider views the patient’s complaints and symptoms. For example, if a patient has a history of substance abuse, the provider might view complaints about pain as drug-seeking behavior. Although this impulse might be accurate, the patient could potentially have a legitimate clinical issue.
Additionally, negative feelings about a patient can cause a provider to consciously or subconsciously blame the patient for his/her symptoms or condition — a bias called attribution error. For example, a patient’s obesity might be attributed to laziness or general disregard for health and wellness. Similarly, a patient who does not adhere to his/her care plan might be viewed as difficult — in reality, though, the nonadherence might be related to financial issues or another cause.
Attribution error also is common in elderly patients because clinicians have a tendency to attribute these patients’ symptoms to advancing age or chronic complaining, rather than exploring other potential causes.7
Positive feelings about patients also can affect diagnostic decisions. In outcome bias, for example, a provider might overlook certain clinical data in order to select a diagnosis with better outcomes. By doing so, the clinician is placing more value on what he/she hopes will happen, rather than what might realistically happen.
In addition to positive and negative feelings about patients, clinician and patient characteristics — such as age, gender, socioeconomic status, and ethnicity — also can affect the diagnostic process. For example, research has shown that various implicit and explicit biases related to race, ethnicity, and gender can affect pain management decisions.8
A variety of other factors also can affectively influence a clinician’s reasoning, such as:
- Environmental circumstances, e.g., high levels of noise or frequent interruptions
- Sleep deprivation, irritability, fatigue, and stress
- Mood disorders, mood variations, and anxiety disorders9
More recent research continues to expand the concepts of cognition and clinical reasoning by viewing it through the lens of situativity, an umbrella term used to describe a series of cognitive theories that examine clinical judgment and reasoning in the context of the situations in which they occur.
These theories move “beyond individual beliefs and knowledge construction to consider those present during the encounter (e.g. the patient and his/her family members, other health care workers, learners), the multiple environmental inputs (e.g. appointment length, artifacts such as electronic health record [EHR] functionality, culture), and their dynamic interactions.”10
The complex interaction between cognitive biases, affective biases/influences, and clinical context can have a profound effect on clinical reasoning and decision-making, which in turn can lead to lapses in clinical judgment and diagnostic errors.
To learn more about the role of clinical judgment in diagnostic errors, including strategies to help improve the diagnostic decision-making process, see MedPro’s article Clinical Judgment in Diagnostic Errors: Let’s Think About Thinking, the Society to Improve Diagnosis in Medicine’s Clinical Reasoning Toolkit, and the Agency for Healthcare Research and Quality’s Diagnostic Safety and Quality website.
Endnotes
1 Cascella, L. M. (2021). Diagnostic errors: A persistent risk. MedPro Group. Retrieved from www.medpro.com/documents/10502/2820774/Diagnostic+Errors-A+Persistent+Risk.pdf
2 Kienle, G. S., & Kiene, H. (2011, August). Clinical judgment and the medical profession. Journal of Evaluation in Clinical Practice, 17(4), 621–627.
3 Phua, D. H., & Tan, N. C. (2013). Cognitive aspect of diagnostic errors. Annals of the Academy of Medicine, Singapore, 42(1), 33–41.
4 Ibid.
5 Clark, C. (2013, August 27). Physicians’ diagnostic overconfidence may be harming patients. HealthLeaders Media. Retrieved from www.healthleadersmedia.com/clinical-care/physicians-diagnostic-overconfidence-may-be-harming-patients; Phua, et al., Cognitive aspect of diagnostic errors.
6 Crosskerry, P., Abbass, A. A., & Wu, A. W. (2008, October). How doctors feel: Affective influences in patient’s safety. Lancet, 372, 1205–1206; Phua, et al. Cognitive aspect of diagnostic errors.
7 Groopman, J. (2008, September/October). Why doctors make mistakes. AARP Magazine, p. 34.
8 Campbell, C. M., & Edwards, R. R. (2012). Ethnic differences in pain and pain management. Pain Management, 2(3), 219–230; Drwecki, B. B. (2015, March). Education to identify and combat racial bias in pain treatment. AMA Journal of Ethics, 17(3), 221–228; Fassler, J. (2015, October 15). How doctors take women’s pain less seriously. The Atlantic. Retrieved from www.theatlantic.com/health/archive/2015/10/emergency-room-wait-times-sexism/410515/; Hoffman, D. E., & Tarzian, A. J. (2001). The girl who cried pain: A bias against women in the treatment of pain. Journal of Law, Medicine, and Ethics, 29, 13-27.
9 Crosskerry, P., et al., How doctors feel.
10 Merkebu, J., Battistone, M., McMains, K., McOwen, K., Witkop, C., Konopasky, A., Torre, D., . . . Durning, S. J. (2020). Situativity: a family of social cognitive theories for understanding clinical reasoning and diagnostic error. Diagnosis, 7(3), 169–176. https://doi.org/10.1515/dx-2019-0100
