Advances in health sciences education : theory and practice
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Adv Health Sci Educ Theory Pract · Sep 2009
Clinical cognition and diagnostic error: applications of a dual process model of reasoning.
Both systemic and individual factors contribute to missed or delayed diagnoses. Among the multiple factors that impact clinical performance of the individual, the caliber of cognition is perhaps the most relevant and deserves our attention and understanding. ⋯ The model has important practical applications for decision making across the multiple domains of healthcare, and may be used as a template for teaching decision theory, as well as a platform for future research. Importantly, specific operating characteristics of the model explain how diagnostic failure occurs.
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Adv Health Sci Educ Theory Pract · Sep 2009
Diagnostic errors in ambulatory care: dimensions and preventive strategies.
Despite an increasing focus on patient safety in ambulatory care, progress in understanding and reducing diagnostic errors in this setting lag behind many other safety concerns such as medication errors. To explore the extent and nature of diagnostic errors in ambulatory care, we identified five dimensions of ambulatory care from which errors may arise: (1) the provider-patient encounter, (2) performance and interpretation of diagnostic tests, (3) follow-up of patients and diagnostic test results, (4) subspecialty consultation, and (5) patients seeking care and adhering to their instruction/appointments, i.e. patient behaviors. ⋯ In this paper, we present a summary of discussion in each of these risk domains. Many novel themes and hypotheses for future research and interventions emerged.
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In this paper, I review evidence from two theories in psychology relevant to diagnosis and diagnostic errors. "Dual Process" theories of thinking, frequently mentioned with respect to diagnostic error, propose that categorization decisions can be made with either a fast, unconscious, contextual process called System 1 or a slow, analytical, conscious, and conceptual process, called System 2. Exemplar theories of categorization propose that many category decisions in everyday life are made by unconscious matching to a particular example in memory, and these remain available and retrievable individually. I then review studies of clinical reasoning based on these theories, and show that the two processes are equally effective; System 1, despite its reliance in idiosyncratic, individual experience, is no more prone to cognitive bias or diagnostic error than System 2. Further, I review evidence that instructions directed at encouraging the clinician to explicitly use both strategies can lead to consistent reduction in error rates.