C.S. Royce is instructor, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. M.M. Hayes is assistant professor, Department of Medicine, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts. R.M. Schwartzstein is professor, Department of Medicine, Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
Acad Med. 2019 Feb;94(2):187-194. doi: 10.1097/ACM.0000000000002518.
Diagnostic errors contribute to as many as 70% of medical errors. Prevention of diagnostic errors is more complex than building safety checks into health care systems; it requires an understanding of critical thinking, of clinical reasoning, and of the cognitive processes through which diagnoses are made. When a diagnostic error is recognized, it is imperative to identify where and how the mistake in clinical reasoning occurred. Cognitive biases may contribute to errors in clinical reasoning. By understanding how physicians make clinical decisions, and examining how errors due to cognitive biases occur, cognitive bias awareness training and debiasing strategies may be developed to decrease diagnostic errors and patient harm. Studies of the impact of teaching critical thinking skills have mixed results but are limited by methodological problems.This Perspective explores the role of clinical reasoning and cognitive bias in diagnostic error, as well as the effect of instruction in metacognitive skills on improvement of diagnostic accuracy for both learners and practitioners. Recent literature questioning whether teaching critical thinking skills increases diagnostic accuracy is critically examined, as are studies suggesting that metacognitive practices result in better patient care and outcomes. Instruction in metacognition, reflective practice, and cognitive bias awareness may help learners move toward adaptive expertise and help clinicians improve diagnostic accuracy. The authors argue that explicit instruction in metacognition in medical education, including awareness of cognitive biases, has the potential to reduce diagnostic errors and thus improve patient safety.
诊断错误导致多达 70%的医疗错误。预防诊断错误比在医疗保健系统中建立安全检查更为复杂；它需要了解批判性思维、临床推理以及做出诊断的认知过程。当发现诊断错误时，必须确定临床推理中的错误发生在何处以及如何发生。认知偏差可能导致临床推理错误。通过了解医生如何做出临床决策，并检查由于认知偏差而导致的错误如何发生，可以开发认知偏差意识培训和去偏策略，以减少诊断错误和患者伤害。教授批判性思维技能的影响研究结果喜忧参半，但受到方法学问题的限制。本观点探讨了临床推理和认知偏差在诊断错误中的作用，以及元认知技能教学对学习者和从业者提高诊断准确性的影响。最近有文献质疑教授批判性思维技能是否会提高诊断准确性，同时也有研究表明元认知实践会带来更好的患者护理和结果。元认知、反思实践和认知偏差意识的教学可能有助于学习者走向适应性专业知识，并帮助临床医生提高诊断准确性。作者认为，在医学教育中明确教授元认知，包括对认知偏差的认识，有可能减少诊断错误，从而提高患者安全性。
