Why Did I Miss the Diagnosis? I Just Didn’t Think of It.

Medical | Mark L Graber MD FACP| March 29, 2018

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In a white paper from EBSCO Health, which includes a forward from Mark Graber, MD, Senior Fellow at RTI International and Professor Emeritus at Stony Brook University, we examine the cause of clinical diagnostic errors.

In one of the classic papers in our field, Dr. Georges Bordage asked a very simple question: “Why did I miss the diagnosis?” The answer is equally simple. “I just didn’t think of it.”

Over the past decade, we have learned a great deal about why this happens. In short, it is System 1’s fault. According to the dual process paradigm that describes how doctors think, if we believe we recognize what’s going on, we assign the diagnosis automatically and subconsciously, using our “intuition.”

According to the dual process paradigm that describes how doctors think, if we believe we recognize what’s going on, we assign the diagnosis automatically and subconsciously, using our “intuition.”

This is System 1. It works remarkably well, is extremely fast and efficient, and best of all, it’s almost always correct. The problem we have in medicine is that “almost always” isn’t good enough.

The mistakes that invariably arise using intuitive thought are the diagnostic errors that lead to inappropriate medical costs, injury, and harm. Cognitive diagnostic errors include:

  • Being in the wrong context
  • Being influenced by someone else’s diagnosis presented to us
  • Accepting the first diagnosis that explains all the facts (premature closure, satisficing)

System 2 is the counterpart to System 1 and represents the deliberate, conscious consideration of all the diagnostic possibilities. Conscious consideration is the antidote to many of the shortcomings of System 1. The deliberate consideration of alternatives may bring something to mind that just wasn’t considered.

Read the white paper to learn how we can overcome the “I just didn’t think of it” problem that underlies much of diagnostic error.

Download Whitepaper

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Mark L Graber MD FACP
President, SIDM

Mark Graber, MD, is a Senior Scientist at RTI’s Health Care Quality and Outcomes Program, and Professor Emeritus of Medicine at the State University of New York at Stony Brook. Dr. Graber has an extensive background in biomedical and health services research, with over 70 peer-reviewed publications. He is a national leader in the field of patient safety and originated, with Ilene Corina of New York, Patient Safety Awareness Week in 2003, an event now recognized internationally. Dr. Graber has been a pioneer and national leader of efforts to address diagnostic errors in medicine. He founded and chaired the Diagnostic Error in Medicine conference series and has several landmark publications on this topic. Currently, Dr. Graber directs an AHRQ ACTION study focused on interventions to reduce diagnostic errors in ambulatory care settings using checklists.

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