1042  American Family Physician www.aafp.org/afp Volume 84, Number 9 ◆ November 1, 2011

Case Scenario

Apatientcametomyofficewitharashunderherarm.Ihadseenheronlyoncebeforefora refillofherdiabetesmellitusmedications.Atthattime,shewasinstructedtoreturnfora comprehensive new-patient examination,whichsheneverscheduled.Onexamination,her vital signs were unremarkable, her glu-cose level was 190 mg per dL (10.55 mmolperL),andshewasobese,withabodymassindexof34kgperm2.Inotedanerythema-tous ring under the left axilla. I concludedthat she had intertrigo and prescribed acortisone/antifungal ointment. I asked herto come back if the rash did not resolve.Shortlyafterward,Itookavacation.WhileIwas away, the patient returned and saw mypartnerforwhatshedescribedaspaininherjoints, particularly her knees. My partnerattributed the pain to arthritis caused byherobesityandprescribedibuprofen.AfewdaysafterIreturned,Ireceivednoticefromarheumatologistfromwhommypatienthadsoughtfurtherconsultationforherrash.Thenote stated that my patient had been diag-nosedwitherythemamigrans,thataninitialLymetiterhadbeenpositive,andthattreat-ment for Lyme disease had been initiated.Lookingback,Irealizethattheerythematousringwithcentralclearingwasconsistentwitherythemamigrans,eventhoughthediagnosisofLymediseasehadnotoccurredtome.IamconcernedthatImissedthis,althoughIhaverecentlymade some luckyguesses thathavebeen life-saving for my patients. How can Imakemydiagnosesmorereliable?

CommentaryManymedicalerrorshavebeenidentifiedassystemic and addressed with interventions,

such as checklists.1 However, a substantialnumberoferrorsthatoccurindiagnosisandtreatment are attributed to flaws in clinicalreasoning.2 It is unknown how often sucherrors occur, but they are most commonin primary care specialties. Some estimatessuggest that diagnostic errors in emergencydepartments occur 5 to 10 percent of thetime.2,3Inasettingwherethereiscontinuityofcare,diagnosticerrorratesarelikelylower.

Errors in diagnostic reasoning are oftenattributedtobiasesorheuristics(Table 13,4).Manybiasesarenothingmore thanpracti-caldiagnosticshortcutsand, inmostcases,actuallyleadtocorrectdecisionmaking.4,5Awide variety of diagnostic biases have beendescribedintheliterature.Theseincludethenotions that common diseases occur moreoften,andthatasinglediagnosisaccountingfornumeroussymptomsisbetterthancob-bling together several explanations. How-ever, at times, pearls become pitfalls. Theycanleadtoerroneousconclusions,asinthiscasescenario.

Thisscenariodemonstratesseveralbiasesthat might interfere with making a correctdiagnosis.Onecommonlydescribedbias isknownas theavailabilitybias,whichrefersto the ease with which a particular answercomes to mind. For example, a physicianmight make a diagnosis based on a recentpatient with similar symptoms. This biasoften excludes diagnostic possibilities, asillustratedbythisphysician’sfailuretocon-sider erythma migrans in the differentialdiagnosis.

Sometimes a constellation of findings(e.g., diabetes, obesity, and underarm rash)suggests one diagnosis more readily thananother. This constellation then becomes a

Flaws in Clinical Reasoning:  A Common Cause of Diagnostic ErrorCommentarybyCAROLINEWELLBERY,MD,Georgetown University School of Medicine, Washington, District of Columbia

Case scenarios are writ-ten to express typical situations that family physicians may encoun-ter; authors remain anonymous. Please send scenarios to Caroline Well-bery, MD, at afpjournal@georgetown.edu. Materi-als are edited to retain confidentiality.

A collection of Curbside Consultations published in AFP is available at http://www.aafp.org/afp/curbside.

Curbside Consultation

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Curbside Consultation

November 1, 2011 ◆ Volume 84, Number 9 www.aafp.org/afp American Family Physician  1043

frame, which is a sort of narrative that disallows otherdiagnoses.Althoughthecasescenariodoesnotprovidethe patient history, another frame might have groupederythematous rash with central clearing, tick bite, andendemicarea.Thisframewouldthenhaveledtothecor-rectpatternrecognition.Disregarding thepossibilityofotherdiagnosesalsocanleadtoprematureclosure.Withthisbias,thephysiciandoesnotseekadditionalinforma-tionafterreachingaconclusionaboutadiagnosis.

Availability and framing biases may anchor a diag-nosis in the physician’s mind, making it hard to dis-lodge. When a patient does not respond to treatment,ananchoringbiaswouldleadaphysiciantoprescribeastrongerdoseoradifferentformulationofapreviouslyprescribed medication rather than consider anotherdiagnosis.Inthisscenario,anchoringmighthavecomeintoplaywhenthepartnerevaluatedthepatient’s jointpain.RatherthanconsideringLymearthritis(although,infact,alatefinding),thephysicianmighthaveassumedfrom the information in the patient’s chart that anysubsequentsymptomswererelatedtooneoftheoriginalfindings (e.g., obesity). Relying on another physician’sopinions illustrates the bias of groupthink, or blindobedience, in which an agreement is reached based onanauthoritativesource(e.g.,laboratoryandimagingtestresults) without sufficient examination. Another bias

associatedwithdiagnostictestsistheconfirmationbias,which leads the interpreter to overemphasize findingsthat support the original diagnosis. As this discussionshows,thereisconsiderableoverlapamongbiases.

How can diagnostic errors be prevented? Unfor-tunately, it is easier to elucidate the barriers to errorprevention than to remedy them. One barrier is thatphysicians often do not get feedback on errors. In thiscase, the physician learned of the error because therheumatologist forwarded the test results, allowing thereceivingphysiciantocomparetheresultswiththepre-vious diagnosis. But this is likely the exception ratherthan the rule. Another barrier is the large number ofshortcuts that physicians are expected to make everydaybecausetheresimplyisnotenoughtimetoevaluateeverydiagnosis.

Interventionstoreducediagnosticerrorsremainspec-ulative,andthereisnofail-safeapproach.Advocatesofmetacognitionsuggestteachingthesourcesofbiasesandimplementing mental awareness practices to counterthem.6 In one study, reflective reasoning was found toreduceavailabilitybiasinresidents.7Physicianswhoana-lyzedaspectrumofdiagnosticpossibilitiesmadeamoreaccuratediagnosisthanthosewhoreliedonapreviouscase with similar features. For practical use of a diag-nostic checklist to reduce error, see the video profiled

Table 1. Diagnostic Biases and Prevention Strategies 

Bias Description Example Corrective strategy

Anchoring Sticking with a diagnosis Continuing to treat a ring-like lesion with antifungals, and the lesion turns out to be discoid lupus erythematosus

Examine the impact of nonresponse or new information on the original diagnosis

Availability Referring to what comes to mind most easily

Making a diagnosis based on a previous patient with similar symptoms

Know baseline prevalence and statistical likelihoods of the condition diagnosed

Confirmation Assigning preference to findings that confirm a diagnosis or strategy

Concluding that leukocyte esterase present on urine dipstick testing in a patient with back pain confirms the patient’s self-diagnosis of kidney infection

Use an objective source (e.g., differential diagnosis checklist, a review of pyelonephritis) to evaluate whether the diagnosis correlates with technical findings

Framing Assembling elements that support a diagnosis

Assuming that symptoms are malarial in a patient who recently returned from Africa

Elicit different perspectives by broadening the history to search for other causes or associations

Premature closure

Failing to seek additional information after reaching a diagnostic conclusion

Failing to note a second fracture after the first has been identified

Review the case, seek other opinions (e.g., radiology backup), and consult objective resources (e.g., an orthopedic review that might include mention of a common concomitant fracture)

Information from references 3 and 4.

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in the followingblogposting:http://commonsensemd.blogspot.com/2011/05/checklists-and-decision-support-in.html.However,interventionssuchasthismaymakeitdifficulttoworkinatimelyandefficientmanner.8

In the case presented, the physician arranged forfollow-up,butfollow-uphaslimitations.Forexample,the rash might have disappeared, in which case thediagnosis might have been delayed despite furtherreview. Little is known about whether point-of-caredecisionmakingreducesmedicalerror;however,con-sultingaproblem-orientedapplicationonahandhelddevice would have provided a broader differentialdiagnosis. Involving team members, such as medicalassistantsornurses,inasystematicwaytogatherhis-torical elements or generate the differential diagnosisalso may be helpful. To illustrate, in a newspaperreportofacaseinvolvingapatientwithLymearthritis,a nurse ultimately made the correct diagnosis whenthepatient’s“mysteriousailment”wasdiscusseddur-ingastaffmeeting,but thiswasafter thepatienthadundergone several unnecessary orthopedic surgeries.9

Although this approach has not been studied, manyphysicians are willing to offer a second opinion for astudent, resident, or colleague to help reach a correctdiagnosis.

Address correspondence to Caroline Wellbery, MD, at wellberc@georgetown.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. Neily J, Mills PD, Young-Xu Y, et al. Association between implementa-tion of a medical team training program and surgical mortality. JAMA. 2010; 304(15): 1693-1700.

2. Scott IA. Errors in clinical reasoning: causes and remedial strategies. BMJ. 2009; 338: b1860.

3. Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010; 44(1): 94-100.

4. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005; 142(2): 115-120.

5. Vickrey BG, Samuels MA, Ropper AH. How neurologists think: a cogni-tive psychology perspective on missed diagnoses. Ann Neurol. 2010; 67(4): 425-433.

6. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003; 41(1): 110-120.

7. Mamede S, van Gog T, van den Berge K, et al. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medi-cine residents. JAMA. 2010; 304(11): 1198-1203.

8. Ely JW, Graber ML, Croskerry P. Checklists to reduce diagnostic errors. Acad Med. 2011; 86(3): 307-313.

9. Boodman SG. Nurse solves mysterious ailment that puzzled ortho-pedists, oncologist. Washington Post. September 27, 2010. http://www.washingtonpost.com/wp-dyn/content /article /2010/09/27/AR2010092706173.html. Accessed June 28, 2011. ■

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