Clinician Cognition

Published on July 11, 2015
From the Managing Editor

Lately, I’ve been thinking a lot about the brain. In particular, my brain—and even more particularly, my basal ganglia—and why my own neuropathways in that region have somehow managed to encode and circumscribe any number of annoying behavior patterns and subconscious biases that affect my (hypothetical!) propensity to put off chores or to make a gratuitous purchase. I am predisposed to these musings, because I have edited and written hundreds of articles on the psychiatric and neurocognitive literature over the course of my career. So I welcomed Senad Tabakovic’s contribution in which he explores the brain’s role in forming a diagnostic “gut feeling” in the ED (The Gut Feeling).

Skillful clinical diagnosis is especially crucial in the ED where, as Dr. Tabakovic points out, patients are usually complete strangers, and medical histories are either incomplete or unavailable, but EPs are nevertheless required to make rapid and thorough diagnostic judgments. Naturally, EPs recognize repeated patterns and experiences over time that help them comfortably arrive at a diagnosis based on patient presentation, observation, available labs, etc. In other words, heuristic strategies. More common diagnoses will therefore come to mind more quickly, leading to more efficient diagnosis, yet more complex presentations will interrupt those heuristics and force the mind to enter a more cognitively taxing evaluative strategy.

These deductive diagnostic processes are generally the most complex cognitive behaviors the EP will undertake, according to Pat Croskerry, a Canadian EP who has written an extensive body of literature on the cognitive processes (and errors) of EM diagnosis. Given its fast pace and high levels of uncertainty, Dr. Croskerry writes that EM is especially prone to diagnostic errors, which he says are fundamentally cognitive errors made by hard-working and well-intentioned physicians, owing to internal biases, copious inherent distractions in the ED, or fatigue. The way to avoid more of these cognitive errors is to adopt a working knowledge of “cognitive forcing strategies,” which are intended to force self-monitoring of one’s decision-making, and to limit potential biases and to control for them. Just like developing a gut feeling, this also happens with acquiring greater clinical experience, as in recognizing particular diagnostic pitfalls, which could be associated with painful lessons learned in the past.

The point is that working harder, or being more careful, won’t really shake the building blocks of our cognitive processes. Sharpening the mind requires an extrinsic intervention. And that can be a painful process. It can mean admitting that you were wrong, or, heaven forbid, being open to critique. I get a taste of that process as an editor in reshaping a piece of editorial. While often uncomfortable for writer and editor alike, the process of critical pushback and the ensuing engagement is the most pleasing aspect of my job; it allows me to support in my way the marvelous EPs around the world who work against great adversity to bring better health to millions. I am stumbling amidst giants in the field of global EM, and I am grateful for your work, all. My hope is that this issue of EPI finds you ever productive, ever humble, and ever reflective.

Mr. Stoltzfoos is the managing editor of EPI.

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