Diagnostic errors and reflective practice in medicine.

BACKGROUND Adverse effects of medical errors have received increasing attention. Diagnostic errors account for a substantial fraction of all medical errors, and strategies for their prevention have been explored. A crucial requirement for that is better understanding of origins of medical errors. Research on medical expertise may contribute to that as far as it explains reasoning processes involved in clinical judgements. The literature has indicated the capability of critically reflecting upon one's own practice as a key requirement for developing and maintaining medical expertise throughout life. OBJECTIVES This article explores potential relationships between reflective practice and diagnostic errors. METHODS A survey of the medical expertise literature was conducted. Origins of medical errors frequently reported in the literature were explored. The potential relationship between diagnostic errors and the several dimensions of reflective practice in medicine, brought to light by recent research, were theoretically explored. RESULTS AND DISCUSSION Uncertainty and fallibility inherent to clinical judgements are discussed. Stages in the diagnostic reasoning process where errors could occur and their potential sources are highlighted, including the role of medical heuristics and biases. The authors discuss the nature of reflective practice in medicine, and explore whether and how the several behaviours and reasoning processes that constitute reflective practice could minimize diagnostic errors. Future directions for further research are discussed. They involve empirical research on the role of reflective practice in improving clinical reasoning and the development of educational strategies to enhancing reflective practice.

[1]  Nancy Franklin,et al.  Reducing Diagnostic Errors in Medicine: What's the Goal? , 2002, Academic medicine : journal of the Association of American Medical Colleges.

[2]  C J McDonald,et al.  Medical Heuristics: The Silent Adjudicators of Clinical Practice , 1996, Annals of Internal Medicine.

[3]  D. Schoen,et al.  The Reflective Practitioner: How Professionals Think in Action , 1985 .

[4]  B. Bornstein,et al.  Rationality in medical decision making: a review of the literature on doctors' decision-making biases. , 2001, Journal of evaluation in clinical practice.

[5]  Kirsti Malterud,et al.  Reflexivity and metapositions: strategies for appraisal of clinical evidence. , 2002, Journal of evaluation in clinical practice.

[6]  F. Wolf,et al.  Understanding our mistakes: a primer on errors in clinical reasoning , 2003, Medical teacher.

[7]  JF Bion,et al.  Challenges in the care of the acutely ill , 2004, The Lancet.

[8]  Pat Croskerry,et al.  Cognitive forcing strategies in clinical decisionmaking. , 2003, Annals of emergency medicine.

[9]  Carol D. Berkowitz,et al.  Primary Care: Concept, Evaluation, and Policy , 1994 .

[10]  K. Hall.  Reviewing intuitive decision‐making and uncertainty: the implications for medical education , 2002, Medical education.

[11]  R. Epstein,et al.  Mindful practice. , 1999, JAMA.

[12]  H. Schmidt,et al.  A cognitive perspective on medical expertise: theory and implication [published erratum appears in Acad Med 1992 Apr;67(4):287] , 1990, Academic medicine : journal of the Association of American Medical Colleges.

[13]  G. Maudsley,et al.  ‘Science’, ‘critical thinking’ and ‘competence’ for Tomorrow’s Doctors. A review of terms and concepts , 2000, Medical education.

[14]  H P Boshuizen,et al.  Scripts and Medical Diagnostic Knowledge: Theory and Applications for Clinical Reasoning Instruction and Research , 2000, Academic medicine : journal of the Association of American Medical Colleges.

[15]  A. Elstein,et al.  Clinical problem solving and diagnostic decision making: selective review of the cognitive literature , 2002, BMJ : British Medical Journal.

[16]  J. Dewey,et al.  How We Think , 2009 .

[17]  Donald A. Sch.  The reflective practitioner: how professionals think in action , 1983 .

[18]  S. Brookfield,et al.  Developing Critical Thinkers , 1987 .

[19]  D. Garrison.  Critical Thinking and Adult Education: A Conceptual Model for Developing Critical Thinking in Adult Learners. , 1991 .

[20]  Geoffrey R. Norman,et al.  The Non-Analytical Basis of Clinical Reasoning , 1997, Advances in health sciences education : theory and practice.

[21]  J. Kassirer,et al.  Learning Clinical Reasoning , 1991 .

[22]  M. Tonelli.  The philosophical limits of evidence‐based medicine , 1998, Academic medicine : journal of the Association of American Medical Colleges.

[23]  P. Croskerry.  The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them , 2003, Academic medicine : journal of the Association of American Medical Colleges.

[24]  Kevin W Eva,et al.  The Aging Physician: Changes in Cognitive Processing and Their Impact on Medical Practice , 2002, Academic medicine : journal of the Association of American Medical Colleges.

[25]  Silvia Mamede,et al.  The structure of reflective practice in medicine , 2004, Medical education.

[26]  D Spruijt-Metz,et al.  Variation in diagnoses: influence of specialists' training on selecting and ranking relevant information in geriatric case vignettes. , 1996, Social science & medicine.

[27]  G R Norman,et al.  The Epistemology of Clinical Reasoning: Perspectives from Philosophy, Psychology, and Neuroscience , 2000, Academic medicine : journal of the Association of American Medical Colleges.

[28]  G. Reader,et al.  Primary Care: Concept, Evaluation, and Policy , 1992 .