Diagnostic Failure: A Cognitive and Affective Approach

Abstract

Diagnosis is the foundation of medicine. Effective treatment cannot begin until an accurate diagnosis has been made. Diagnostic reasoning is a critical aspect of clinical performance. It is vulnerable to a variety of failings, the most prevalent arising through cognitive and affective influences. The impact of diagnostic failure on patient safety does not appear to have been fully recognized. Ideally, all information used in diagnostic reasoning is objective and all thinking is logical and valid, but these conditions are not always met. Two major phenomena that may undermine objectivity and rational thinking are cognitive dispositions to respond (CDRs) and affective dispositions to respond (ADRs) toward the patient. In this report, the determinants and characteristics of the major CDRs and ADRs are reviewed, as are a variety of de-biasing strategies that may mitigate their influence. A retrospective analytical process, the cognitive and affective autopsy, is also described. The purpose of this report is to provide insight into cognitive and affective influences that have resulted in delayed or missed diagnoses.

The theory and practice of clinical decision-making

“…20,21 These are summarized in Table II. The compendium does not include four further categories of bias that may arise in the course of diagnostic test evaluation: verification or work-up bias, diagnostic review bias, test review bias and incorporation bias, 3 nor does it include a number of affective biases that have been described. 22,23 Collectively, these known cognitive/affective and other biases in the diagnostic process would currently yield a total in excess of 40, and there are probably more.…”

Emotionality in Computer-Mediated Environments: Analyzing the Emotional Content of Psychotherapeutic Communication

“…Therefore affective bias may have a major impact in CMP [61,62]. A few studies have addressed how telecounseling affects the vicarious traumatization, or how much burnout in cybertherapists can be estimated [63,64].…”

Use of a novel, modified fishbone diagram to analyze diagnostic errors

“…However, the study does not comment on the widely acknowledged contributions of the individual cognitive processes to many diagnostic errors, as described by Croskerry [11]. Because diagnostic errors so frequently result from multiple factors, the approach to diagnostic error analysis should be comprehensive and include consideration of systembased, team-based and individual-bases cognitive factors, an approach Croskerry calls the "cognitive autopsy" [12].…”