“Preflight Checklists” for diagnosis: a personal experience

Abstract

As physicians, we take pride in our ability to generate, from memory, a complete differential diagnosis for our patients' presenting symptoms. We expect this of ourselves and our trainees, but we do not do it reliably. Studies have found that the most common cause of diagnostic error is the physician's failure to consider the correct diagnosis as a possibility. Other professionals, like airline pilots and nuclear plant operators, have accepted the fallibility of their memories and have learned how to ensure reliable completion of critical tasks by using checklists. But our culture in medicine glorifies physicians who complete the critical task of diagnosis using their memories and disparages those who cheat by referring to a list. Recent studies have supported the use of checklists in the operating room and intensive care unit, but so far they have not been used to make diagnosis more reliable. This essay explores a possible use for differential-diagnosis checklists by describing the author's experience with them in a primary care clinic.

The Rational Diagnostician and Achieving Diagnostic Excellence

“…Cognitive forcing strategies, such as promoting clinical maxims like "always develop a differential diagnosis," "rule out worst-case scenario," "until proved otherwise," and "consider the opposite," offer some protection against biases that commonly interfere with the diagnostic process. The routine use of differential checklists, alerting the decision maker to diseases commonly missed, as well as those that must not be missed, 8 the judicious use of clinical decision support, and the application of clinical decision rules could help overcome some predictable intuitive pitfalls. Mitigating judgment and decision-making biases is emerging as a critical goal for many human endeavors.…”

Diagnosing Diagnosis

“…It has been heavily dominated by physicians with little input from the cognitive sciences, 2 focusing mostly on potential interventions-checklists, mnemonics, ground rules, computerized decision support, or exhortations (essentially amounting to "be more Protestant")-aimed at overcoming the defects believed to exist in current practices. [3][4][5][6][7][8] What is missing, however, is foundational work aimed at understanding how clinicians in actual situations take a complex, tangled stream of phenomena and select some to create an understanding of them as a "problem. "…”